THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GEORGE  B.  WINTER,  D.D.S.,  St.  Louis,  Mo. 

President  of  the  American  Dental  Association 


EXODONTIA 

Influence  of  George  B.  Winter  on  Development  of 
Sxodontia.  Frank  W.  Kouuds^  (Boston)  recalls  that 
25  years  ago  an  unknown  author  completed  a  textbook 
on  the  extraction  of  the  teeth.  Since  that  time,  the  name 
of  George  B.  Winter  has  become  an  international  syno- 
nym for  things  that  pertain  to  the  present  concept  of 
the  principles  and  practice  of  tooth  extraction. 

George  Ben  Wade  AVinter  was  born  in  Brooklyn,  in 
1878.  His  father,  a  newspaper  man,  whose  work  took 
him  to  various  cities,  finally  settled  in  St.  Louis.  Even- 
tually he  left  the  financially  precarious  field  of  news- 
paper work,  entered  business  and  achieved  moderate 
success  until  the  panic  of  1897  engulfed  him.  At  16, 
George  was  dependent  on  his  own  resources  for  further 
education  and  livelihood.  By  his  own  endeavors,  he 
worked  his  way  through  elementary  and  high  schools 
and  carried  on  to  obtain  his  professional  education. 

Winter  carried  on  a  general  dental  practice  for  a 
few  years.  He  gives  great  credit  to  such  leaders  as 
Edward  Angle  and  A.  Bromley  Allen  in  shaping  his 
destim*.  Endowed  with  a  restless  spirit  which  impelled 
him  to  progress  from  one  accomplishment  to  another. 
Winter  was  unsatisfied  with  a  merely  creditable  show- 
ing. He  decided  to  specialize  in  the  field  that  he  liked 
best  and  for  which  he  had  shown  the  greatest  aptitude. 
In  this  phase  of  practice  he  became  a  leader,  but  once 
more  his  innate  desire  for  progress  became  insistent. 
He  was  convinced  that  methods  of  tooth  extraction 
could  be  improved.  His  experience  as  a  teacher  in  St. 
Louis  University  led  him  to  the  realization  that  the 
means  of  instruction  were  decidedly  limited  and  far 
less  efficient  than  one  could  wish.  The  literature  in  this 
special  field  was  meager.    The  crude  methods  of  the 

(TT     Am.  J.   Orthodont.  26:285-289,  March,   1940. 
411 


412  ORAL  SURGERY 

day  made  clinical  demonstration  unsatisfactory  to  the 
exacting  scientist.  Asked  to  conduct  a  course  of  sev- 
eral lectures,  he  found  that  the  sum  of  published  knowl- 
edge on  this  subject  could  be  told  in  a  limited  time 
and  that  the  material  was  a  hodgepodge  of  random 
information. 

The  next  four  years  were  spent  in  intensive  research, 
from  which  Winter  evolved  a  basic  scientific  principle 
on  which  tooth  movement  during  extraction  was  estab- 
lished. In  1913,  he  was  ready  to  publish  his  findings; 
25  years  ago  he  produced  his  textbook  on  the  extraction 
of  teeth.  This  book  was  the  first  comprehensive  work 
on  this  subject  that  had  ever  been  brought  to  pro- 
fessional attention.  He  captioned  it  with  a  title  that 
has  not  only  become  standard  in  the  science  of  tooth 
extraction  but  designates  the  individual  who  specializes 
in  the  removal  of  teeth.  The  thought  and  study  given 
to  this  detail  typifies  the  thoroughness  with  which 
Winter  undertook  every  task. 

Before  a  word  was  put  on  paper  and  before  even 
one  of  the  many  illustrations  was  planned,  it  was  first 
necessary  for  Winter  to  do  the  thing  he  was  to  write 
about,  not  once,  but  thousands  of  times,  so  that  the 
technic  might  be  perfected.  He  must  be  absolutely 
certain  that  he  was  right.  As  a  result  of  this  original 
research,  he  coined  the  word  ''exodontia"  and  dignified 
the  specialist  with  the  name  "exodontist."  He  created 
a  new  specialty.  Most  research  is  based  on  and  is  a 
development  of  an  extensive  literature  left  by  earlier 
workers.  Winter  had  no  such  background,  for  he  was 
investigating  a  scientific  frontier.  In  fact,  it  was  lack 
of  earlier  scientific  investigation  that  led  him  to  in- 
augurate his  studies. 

This  text  on  exodontia  created  enormous  interest 
among  dental  men.  The  small  edition  of  only  5,000 
copies  was  soon  exhausted.  It  is  now  listed  among  rare 
works,  and  a  large  premium  must  be  paid  to  obtain  a 
copy  today.    The   last   chapters   were   devoted   to   the 


EXODONTIA  413 

removal  of  impacted  teeth.  No  sooner  was  the  work 
published  than  the  author  became  dissatisfied  with  this 
section.  At  that  time  the  x-ray  was  new  and  roentgeno- 
graphs were  often  inadequate.  Once  more,  Winter 
started  research.  There  were  many  cases  of  impacted 
teeth  which  clinical  examination  had  failed  to  reveal. 
He  felt  the  need  of  a  definite  operative  procedure  to 
eliminate  the  brutality  and  trauma  which  accompanied 
their  removal.  The  revelations  made  by  improved  x-ray 
technic  which  he  mastered,  combined  with  the  knowl- 
edge and  experience  gained  by  his  investigations,  con- 
vinced him  that  such  methods  were  unnecessary.  Dur- 
ing 12  years  he  studied  thousands  of  impacted  teeth, 
preoperatively,  operatively  and  postoperatively.  The 
world  was  searched  for  mandibles  of  man  from  pre- 
historic times  to  the  present.  All  findings  were  pains- 
takingly tabulated  and  classified.  As  a  result,  in  1926 
Winter  had  completed  a  text  of  819  pages  devoted  to 
the  mandibular  third  molar  when  impacted.  It  was 
amplified  with  hundreds  of  illustrations,  which  alone 
rendered  the  classifications  visible  to  the  student  and 
exemplified  the  operative  procedure  in  detail. 

This  edition  was  soon  exhausted.  Even  operators  who 
did  not  wish  to  master  the  technic  for  their  practice 
were  thoroughly  convinced  that  the  comprehensive 
classification  was  correct.  It  was  felt  that  the  last 
word  had  been  said  and  written  on  this  subject.  In 
the  author's  mind,  however,  there  still  remained  further 
work  to  be  done.  At  the  International  Congress  in 
Paris  in  1932,  he  felt  that  he  had  found  the  medium 
he  needed.  On  his  return,  he  immediately  investigated 
the  possibilities  for  producing  scientific  motion  pictures 
to  illustrate  his  work.  After  long  experimentation,  he 
completed  his  first  production,  a  silent  movie  which 
was  shown  all  over  the  United  States  and  abroad  with 
such  success  that  again  he  was  stimulated  to  further 
efforts.  It  M^as  a  short  but  logical  step  to  the  talking 
picture.   Winter's  new  sound  movie  was  first  presented 


414  ORAL  SURGERY 

at  the  Second  District  Dental  Society  of  Brooklyn,  in 
1936.  The  results  of  all  his  years  of  research  and  inves- 
tigation were  so  clearly  demonstrated  by  this  means 
that  they  were  easily  available.  This  method  of  propa- 
gating scientific  investigation  has  attracted  universal 
attention.  Boldly  and  convincingly,  he  has  put  before 
the  dental  profession  the  fascinating  probability  that 
in  the  future  much  constructive  dental  teaching  will  be 
based  on  this  new  type  of  visual  education. 

[In  his  resume  of  the  life  and  work  of  George  B.  Winter, 
Rounds  has  paid  tribute  to  one  whose  years  of  effort,  research 
and  many  contributions  so  greatly  influence  the  advancements 
made  in  exodontia. 

In  presenting  this  article  at  somewhat  greater  length  than  is 
ordinarily  followed  in  abstracting  an  original  contribution,  this 
section  of  the  Year  Book  of  Dentistry  is  desirous  of  joining  with 
members  of  the  dental  and  medical  profession  in  honoring  Dr. 
Winter  and  showing  their  appreciation  for  the  many  contributions 
he  has  made  to  the  field  of  dentistry. — Ed.] 

Mandibular  Third  Molar.  The  following  series  of  re- 
ports,^ selected  because  of  the  ever-growing  importance 
of  this  subject  in  the  field  of  oral  surgery,  were  taken 
from  the  issue  of  the  Archives  dedicated  to  George  B. 
Winter  in  appreciation  of  the  outstanding  importance 
of  the  work  he  contributed  to  this  field  of  dentistry. 

Development  of  the  Occlusal  Roentgenogram. — George 
B.  Winter  believed  that  the  optimum  position  for  the 
occlusal  view  film  is  obtained  by  placing  the  film  flat 
on  the  first  and  second  molars  and  moving  it  distally 
until  it  comes  in  contact  with  the  ascending  ramus. 
The  anterior  edge  then  is  over  or  just  distal  to  the 
mesial  surface  of  the  first  molar.  The  final  analysis 
of  the  salient  points  to  be  obtained  by  the  occlusal  view 
roentgenogram  follows.  It  definitely  establishes  the 
available  fulcrum  for  leverage.  The  heavy  cortical 
plate  buccal  and  mesiobuccal  to  the  third  molar  is  used 
for  leverage  in  instrumentation  and  is  important  for 
the  final  delivery.  It  shows  the  ossistructure  lingual 
to  the  tooth  and  definitely  eliminates  it  for  use  as  a 

(5)      Arfh.   Olin.   Oral   Path.   4:239  ff.,    Sept.-Dec,    1940. 


d{J 


EXODOXTIA 


TECHNK'  OF  KXTRACTION  OF  TEKTH 


/^  //^ 


EXODONTIA 


A  PRA(  FK  AL   TllEATISE  ON   THE   TECHNIC  OF 
EXTRACTION   OF   TEETH 

A\  ITH   A   CHAPTEK   ON   ANESTHESIA 


A  COMPLETE  GUIDE  FOR  THE  EXODONTIST,  GENERAL 
DENTAL  PRACTITIONER,  AND  DENTAL  STUDENT 


BY 

GEORGE  B.  WINTER,  D.  D.  S. 

PROFESSOR  OF   EXODONTIA  AND  LECTURER  ON  ANESTHESIA,    ST.   LOXHS   UNIVERSITY 

SCHOOL  OF   DENTISTRY 


ILLUSTBATED  WITH  245  ORIGINAL  ENGRAVINGS 


ST.  LOUIS 

AMERICAN  MEDICAL  BOOK  COMPANY 

1913 


Copyright,  1913,  v.y  American  Medical  Book  Company 


Press  of 

American  Medical 

Book  Company 


lAlU 


THIS  VOLUME  IS  DEDICATED 
TO 

A.  BROM  ALLEN,  D.  D.  S. 

MAY  THE  INFORMATION  SOUGHT  TO  BE  CONVEYED  IN 
THIS  BOOK  BE  AN  AID  TO  A  COMPLETE  CONCEPTION 
OF    THE    PRINCIPLES    OF    EXODONTIA    IS    THE   WISH    OF 

THE  AUTHOR 


PRE:FACE 

In  presenting  this  volume  on  Exodontia  it  is  the  aim  of  the 
author  to  submit  a  more  extensive  treatise  on  this  subject  than 
has  heretofore  been  published.  This  effort  to  prepare  a  book 
that  is  comprehensive  has  been  stimulated  largely  by  the  fact 
that  only  brief  reference  to  this  important  subject  occurs  in 
works  on  operative  dentistry.  It  has  been  the  plan  to  limit 
the  scope  of  the  book  to  the  subject  of  extraction,  with  an 
endeavor  to  treat  that  feature  in  a  manner  so  complete  and 
practical  as  to  fully  meet  the  requirements  of  the  exodontist, 
general  practitioner,  and  dental  student. 

The  rapid  and  appreciable  progress  that  has  been  made  in 
dentistry  in  recent  years  is  an  indication  that  indefatigable 
scientific  research  in  this  profession  has  been  instrumental  in 
improving  the  technic  of  operation  in  the  various  branches  of 
this  calling,  and  the  technic  of  extracting  a  tooth  from  its  sup- 
porting tissues  has  advanced  at  least  equally  with  that  of  the 
other  branches.  The  advancement  made  in  Exodontia  has  been 
the  means  of  reducing  tentative  methods  of  operating  to  a  sys- 
tem, and  has  thus  established  definite  methods  of  procedure  for 
the  various  cases. 

In  treating  the  subject  of  Exodontia  it  has  been  the  intention 
to  prescribe  methods  of  operation  that,  with  such  slight  changes 
in  the  technic  of  procedure  as  the  peculiar  condition  of  an  un- 
usual case  may  indicate,  will  be  applicable  to  any  case  that  may 
be  presented,  as  it  is  impossible  to  establish  an  immutable  rule 
to  be  followed  in  all  cases.  Exodontia  is  a  branch  of  surgery 
in  which  operations  are  more  frequently  performed  than  in  any 
other  division  of  the  surgical  art,  and  there  are  cogent  reasons 
why  the  removal  of  a  certain  tooth  from  its  retaining  tissues 
should  be  performed  with  as  much  precision  and  governed  by 
as  specific  rules  as  any  other  distinctive  surgical  operation. 

Operative  skill  in  Exodontia  is  to  be  acquired  only  by  careful 
study  and  practical  experience,  and  it  should  be  the  ambition  of 
the  operator  to  so  prepare  himself  as  to  be  able  to  form  a  proper 


YIII  PREFACE 

conceptiou  of  the  procedures  to  be  followed  in  the  various  cases 
of  extraction  that  may  be  presented. 

With  a  view,  therefore,  of  furnishing  a  guide  for  correct  opera- 
tive work,  the  technic  of  various  operations  and  methods  of 
after-treatment  are  given  in  detail.  The  extraction  of  normal 
teeth  in  the  numerous  stages  of  decay,  the  different  malposi- 
tions, and  the  most  frequent  forms  of  abnormalities  of  teeth  have 
been  carefully  treated.  Variations  in  surrounding  tissues  and 
their  pathologic  conditions  have  been  described,  and  the  divers 
forms  of  fracture  cases  have  been  discussed.  The  important 
matter  of  position  of  patient  and  operator,  together  with  the 
selection  and  application  of  suitable  instruments,  have  been  pre- 
sented in  a  manner  that  will  be  readily  understood.  Practical 
methods  of  diagnosis,  particularly  in  those  cases  where  obscure 
conditions  indicate  resort  to  radiography,  have  been  explained, 
with  the  aid  of  special  illustrations,  in  a  manner  that  will  be 
helpful  to  the  operator.  Some  space  has  also  been  devoted  to 
the  subject  of  general  and  local  anesthesia,  as  the  administra- 
tion of  anesthetics  in  the  extraction  of  teeth  is  an  important 
adjunct  to  the  operation. 

Pains  have  been  taken  to  have  the  illustrations,  all  of  which 
have  been  prepared  especially  for  this  book,  made  as  nearly 
perfect  as  illustrative  art  and  mechanical  execution  can  produce. 
It  will  be  observed  tliat  not  only  the  illustrations  of  instruments 
are  presented  with  a  high  degree  of  resemblance  to  the  actual 
object,  but  that  the  illustrations  of  normal  and  abnormal  condi- 
tions of  teeth  and  tissues,  as  well  as  the  methods  of  the  operation, 
are  shown  with  i-emarkable  correctness. 

G.  B.  W. 


( ONTENTS 

CHAPTER  I 

HISTORICAL 

Chkonological  Development 2 

Progress  of  Modern  Methods 6 

CHAPTER  II 
INSTRUMENTS 

Forceps  8 

Forceps  for  Superior  Teeth 10 

Forceps  for  Inferior  Teetli 16 

Special  Forceps 22 

Elevators 28 

Straiglit-Shank   Elevator 29 

Curved-Shank    Elevator 30 

Knott  Elevator 32 

Author's  Lower  Root  Elevator 33 

Lecluse  Elevator 35 

Cryer  Elevator 38 

Screw-Fortes  and  Readier 41 

Screw-Portes 41 

Morrison  Reamer 41 

Keith  Screw-Porte 44 

Derenberg  Tweezers 45 

Lancet 45 

Curved  Scissors 47 

Syringes 47 

Standard  Syringe 47 

Bismuth   Syringe 48 

CURET , 49 

Mouth-Gag 49 

Wooden  Wedge 51 

Retractor 53 

Chisel 53 

Instruments  for  Examination 54 

Mouth  Mirror 54 

Foil  Carrier 54 

Explorer 55 

Probe 55 

CHAPTER  III 
OFFICE  EQUIPMENT 

Operating   Room 56 

Operating  Chair 57 

Foot-Stand 57 

IX 


X  CONTENTS 

Operating  Room — Cont'd.  Page 

Cabinet 57 

Sterilizing  Vase 58 

Cuspidor 58 

Pus  Pan 58 

Artificial  Light 59 

Nitrous  Oxid  Apparatus 59 

Dental  Engine 59 

Sterilizer 59 

Toilet  Accessories 60 

Care  of  the  Patient 61 

Reception  Room 61 

Rest  Room 61 

Attendant 62 

CHAPTER  IV 

ANATOMICAL  LANDMARKS 

Dento-Osseous  Structures 63 

Labially 63 

Buccally 64 

Palatally 65 

Lingually 67 

Roots  of  the  Anterior  Teeth 68 

Roots  of  the  Posterior  Teeth 68 

lArpoRT  of  Anatomical  Landmarks 69 


CHAPTER  V 

INDICATIONS  AND  COUNTERINDICATIONS  FOR   EXTRACTION 

Coxditioxs  that  IxnicATE  Extraction 70 

Pathologic  Conditions 70 

Impacted  Teeth 71 

Supernumerary  Teeth 71 

Malposed  Teeth 71 

Fractured  Teeth 71 

Roots  Supporting  Crown  or  Bridge 72 

Artificial  Dentures 72 

Deciduous  Teeth 72 

Surgical  Cases 72 

Traumatism 72 

Neuralgia 72 

Infirmities 72 

Conditions  that  Do  Not  Indicate  Extraction 73 

Coitxterindications  to  Operating 74 

Heart  Lesion 75 

Abscessed  Teeth 75 

Temporary  Ankylosis 75 

Hemorrhagic   Diathesis 76 

Pregnancy 76 

Epilepsy 76 


CONTENTS  XI 

CHAPTER  VI 

EXAMINATION  OF  THE  MOUTH   AND  TEETH 

Page 

Attitude  of  the  Operator  when  Making  an  Examination 77 

Examining  the  Mouth 78 

Removing  Foreign  Bodies  Preceding  Examination  and  Operation  ....  79 

SuRGiCAi.  Diseases  About  the  Mouth 79 

Examining  the  Tooth,  Adjacent  Teeth,  and  Tissues 80 

Examining  a  Tooth  Free  of  Caries 81 

Examining  a  Tooth  with  a  Fractured  Crown 81 

Examining  a  Tooth  with  Checked  Enamel 82 

Examining  a  Tooth  Attacked  by  Caries 82 

Examining  the  Root  of  a  Tooth 83 

Examining  a  Root  Overlaid  with  Gum  Tissue 84 

Examining  a  Filled  Tooth 84 

Examining  a  Root  Supporting  a  Shell  Crown 84 

Examining  a  Root  Supporting  a  Dowel  Crown 85 

Examining  a  Bridge  Abutment 85 

Examining  a  Treated  Tooth 85 

Examining  the  Adjacent  Teeth  and  Approximating  Space 85 

Examining  the  Gums 86 

Examining  the  Alveolar  Process 86 

Use  of  the  Radiograph  in  Examination 87 

Intraoral  Radiograph 87 

Extraoral  Radiograph 88 

When  the  Radiograph  is  Indicated 89 

Impacted  Tooth 89 

Deep-Seated  Root 90 

Suspected  Unextracted  Root 90 

Tooth  or  Root  Below  a  Bridge 90 

Abscessed  Tooth 90 

Unerupted  Tooth 91 

Deciduous  Tooth 91 

Maxillary  Sinus 91 

Other  Conditions       ■ 91 

Procedure  Outlined 92 

CHAPTER  VII 
POSITION  OP  THE  PATIENT  AND  OPERATOR 

Position  for  Operation  on  the  Superior  Teeth 93 

Position  of  the  Patient  for  Operation  on  the  Superior  Teeth      ....  93 
Position  of  the  Operator   when   Employing   Forceps   on   the   Superior 

Teeth 94 

Position  for  Operation  on  the  Inferior  Teeth 96 

Position  of  the  Patient  for  Operation  on  the  Inferior  Teeth 96 

Position   of  the  Operator   when   Employing   Forceps    on   the    Inferior 
Teeth 


97 


Positions  for  Various  Conditions 


98 


Position  of  the  Operator  when  Employing  Forceps  where  Superior  and 

Inferior  Teeth  are  to  be  Extracted  at  the  Same  Time 98 


XII  CONTENTS 

Positions  for  Various  Conditions — Cont'd.  Page 

Position  of  the  Operator  when  Employing  an  Elevator 99 

Position  of  the  Operator  when  Operating  on  a  Cliild 99 

Position  of  the  Operator  when  Operating  at  the  Home  of  the  Patient  .  100 

Position  of  the  Operator  in  the  Hospital 101 

CHAPTER  VIII 
PRECAUTIONARY  SUGGESTIONS 

Preliminary  Procedure 102 

Time  of  Day  for  Operating 103 

Impaired  Health 103 

Advising  the  Patient  Before  the  Operation 103 

Uncertainty  of  Resistance  Encountered 104 

Tooth  Affected  by  Pyorrhea 104 

Unsuccessful  Operation  by  Another  Operator 105 

Temporary  Ankylosis 106 

CHAPTER  IX 

EXTRACTION  TECHNIC  OF  THE  SUPERIOR  TEETH 

Superior  Central  Incisor 108 

Position  of  Patient  and  Operator 108 

Forceps 110 

Order  of  Extraction  ....          Ill 

Application  of  Forceps Ill 

Alveolar  Application  of  Forceps Ill 

Extraction  Movements 112 

Displacement,  Caries,  Roots,  Fracture 114-120 

Superior  Lateral  Incisor 120 

Position  of  Patient  and  Operator 120 

Forceps 120 

Order  of  Extraction 122 

Application  of  Forceps     .     .              122 

Alveolar  Application  of  Forceps 122 

Extraction  Movements 122 

Displacement,  Impaction,  Caries,  Roots,  Fracture 124-129 

Superior  Cuspid 129 

Position  of  Patient  and  Operator 129 

Forceps 129 

Order  of  Extraction 130 

Application  of  Forceps 130 

Alveolar  Application  of  Forceps 130 

Extraction  Movements 133 

Displacement,  Impaction,  Caries,  Roots,  Fracture 136-140 

Superior  First  and  Second  Bicuspids 140 

Position  of  Patient  and  Operator 140 

P"'orceps 140 

Order  of  Extraction 144 

Application  of  Forceps 144 

Alveolar  Application  of  Forceps 144 

Extraction  Movements 144 

Displacement,  Impaction,  Caries,  Roots,  Fracture 146-153 


CONTENTS  XIII 

Page 

Superior  First  and  Second  Molars 153 

Position  of  Patient  and  Operator 153 

Forceps 153 

Order  of  Extraction 157 

Application    of   Forceps 157 

Alveolar  Application  of  Forceps 158 

Extraction  Movements 159 

Displacement,  Impaction,  Caries,  Roots,  Fracture,  Maxillary  Sinus    .  161-170 

Superior  Third  Molar 170 

Position  of  Patient  and  Operator 172 

Forceps 172 

Order  of  Extraction 172 

Application  of  Forceps 174 

Alveolar  Application  of  Forceps 174 

Extraction  Movements 174 

Displacement,  Impaction,  Caries,  Roots,  Fracture 176-183 

CHAPTER  X 

EXTRACTION  TECHNIC  OF  THE  INFERIOR  TEETH 

Inferior  Incisors 184 

Position  of  Patient  and  Operator 184 

Forceps 187 

Order  of  Extraction 188 

Application  of  Forceps 188 

Alveolar  Application  of  Forceps 189 

Extraction  Movements 190 

Displacement,  Impaction,  Roots,  Fracture 192-196 

Inferior  Cuspid .  196 

Position  of  Patient  and  Operator 196 

Forceps 196 

Order  of  Extraction 198 

Application  of  Forceps 199 

Alveolar  Application  of  Forceps 200 

Extraction  Movements 200 

Displacement,  Impaction,  Caries,  Roots,  Fracture 200-204 

Inferior  First  and  Second  Bicuspids 204 

Position  of  Patient  and  Operator 204 

Forceps 206 

Order  of  Extraction 208 

Application    of   Forceps 208 

Alveolar  Application  of  Forceps 208 

Extraction  Movements 210 

Displacement,  Impaction,  Caries,  Roots,  Fracture 210-220 

Inferior  First  and  Second  Molars 220 

Position  of  Patient  and  Operator 220 

Forceps 222 

Order  of  Extraction 225 

Application  of  Forceps 225 

Alveolar  Application  of  Forceps 225 

Extraction  Movements 226 

Displacement,  Impaction,  Caries,  Roots.  Fracture,  Isolated  Tooth      .  229-248 


XrV  CONTENTS 

Page 

Inferior  Third  Molar 248 

Position  of  Patient  and  Operator 250 

Maximum  Value  of  Elevator 254 

Forceps 255 

Order  of  Extraction 255 

Fulcrum 256 

When  the  Second  Molar  May  be  Used  as  Fulcrum 256 

When  the  Second  Molar  May  Not  be  Used  as  Fulcrum 256 

Methods  of  Reinforcing  the  Fulcrum 257 

Impaired  Fulcrum    . 259 

Use  of  the  Lecluse  Elevator 260 

Extraction  Movements  for  Elevator 263 

Application  of  Forceps 266 

Alveolar  Application  of  Forceps 266 

Extraction  Movements  for  Forceps 267 

Displacement,  Caries,  Roots,  Fracture,  Isolated  Tooth 268-282 

CHAPTER  XI 

EXTRACTION  TECHNIC  OF  IMPACTED  INFERIOR  THIRD  MOLAR 

Etiology 285 

History  and  Nature  of  the  Opeuation 286 

Operative  Technic 286 

Partial   Impaction 287 

Diagnosis 287 

Anesthetic 288 

By  Soft  Tissue 288 

By  Osseous  Tissue 290 

By  Malposition  and  Malformation 291 

By  Supernumerary  Teeth 295 

Complete   Impaction 296 

Radiographic  Diagnosis 296 

Anesthetic 298 

By  Soft  Tissue 299 

By  Osseous  Tissue 300 

By  Insufficient  Space 300 

By  Malposition  and  Malformation 302 

Removing  the  Lingual  Plate 311 

CHAPTER  XII 
DECIDUOUS  AND  SUPERNUMERARY  TEETH 

Deciduous  Teeth 316 

Position  of  Patient  and  Operator 316 

Anatomy 316 

Attitude  of  the  Operator 317 

Anesthetic 317 

Superior  Incisors  and  Cuspids 317 

Superior  First  and  Second  Molars 318 

Inferior  Incisors  and  Cuspids 318 

Inferior  First  and  Second  Molars 319 

Wedged  Roots  of  Deciduous  Teeth 319 


CONTENTS 


XV 


Page 

Supernumerary  Teeth p,19 

Extraction  Technic 320 

Peg-Shaped  Crown 320 

Supernumerary  Teeth  in  the  Vicinity  of  the  Superior  Bicuspids  and 

Molars 321 

Very  Small  Teeth 322 


CHAPTER  xrri 

HYPERCEMENTOSIS  AND  ARTIFICIAL  COMPLICATIONS 

Hypercementosis 323 

Etiology 325 

Diagnosis 325 

Extraction  Technic 326 

Artificial   Complications 328 

Extracting  a  Root  Supporting  a  Dowel  Crown 328 

Utilizing  a  Post  for  the  Extraction 329 

Extracting  a  Tooth  Supporting  a  Shell  Crown 329 

Extracting  a  Bridge  Abutment     . 330 

Extracting  a  Tooth  or  a  Root  Situated  Below  a  Bridge 331 

CHAPTER  XIV 

ACCIDENTS 

FrAC'J  tIRES    OF   THE    TEETH 332 

Causes 332 

Informing  Patient  of  Probable  Fracture 333 

Resulting  Shock 334 

Under  General  Anesthetic 334 

Operative  Technic 335 

Hemorrhage 336 

Fracture  of  the  Alveolar  Process 337 

Fracture  of  the  Maxillary   Tuberosity 337 

Extraction  of  an  Adjacent  Tooth 338 

Extraction  of  oe  Injury  to  an  Unerupted  Tooth 339 

Forcing  a  Tooth  Into  an  Abscess  Cavity 339 

Forcing  a  Tooth  Into  the  Maxillary'  Sinus 340 

Forcing  a  Tooth  Between  the  Tissues 341 

Loosening  an  Adjacent  Tooth 342 

Disturbing  Artificial  Restorations 342 

Disturbing  a  Treatment  in  an  Adjacent  Tooth 343 

Breaking  an  Instrument 343 

Bruising  the  Lip 343 

Bruising  the  Cheek 343 

Wounding  the  Tongue 344 

Dislocation  of  the  Mandible 345 

Fracture  of  the  Jaw 346 

Teeth  Loosened  or  Displaced  by  Accident 347 

Tooth  Passing  Beyond  the  Pharynx 347 


XVI  CONTENTS 


CHAPTER  XV 

TREATMENT  AFTER  EXTRACTION  „,„, 

FAGE 

Examination 349 

Extraction  Without  Complications  .     .         349 

Traumatic  Injury  to  the  Gum  Tissue 351 

Traumatic  Injury  to  the  Alveolar  Process 352 

Loose  Spicula 352 

Sharp  or  Irregular  Margins  352 

Fractured  Margin  and  Septum 352 

Extensive  Fracture 353 

Exposed  Process 355 

Dilated  Socket 356 

Foreign  Bodies  in  the  Socket 359 

Alveolitis 359 

Post-Operative  Alveolitis 361 

Acute  Septic  Pericementitis 361 

Post-Operative  Infection 364 

Toxemia  and  Septicemia 365 

Chronic  Septic  Pericementitis 365 

Septic  Pericementitis  With  External  Fistula 367 

Multiple  Extractions 368 

Necrosis 368 

Maxillary   Sinus 368 

Post-Extraction   Pain 369 

tubekculosis  and  syphilis 370 

Oral  Lesions  Other  than  Dental 370 

CHAPTER  XV r 

HEMORRHAGE  ^ 

Primary  Hemorrhage 372 

I.ntekmediary  Hemorkhage 373 

Secondary  Hemorrhage 375 

Instructing  the  Patient 375 

Excessive  Bleeders 376 

Hemophilia 376 

CHAPTER  XVII 

GENERAL  AND  LOCAL  ANESTHESIA 

General  Anesthesia 378 

General  Anesthetics 381 

Nitrous   Oxid 881 

Composition .     .  381 

Effect  on  the  Organism 382 

The  Patient 383 

Preliminaries 383 

The  Apparatus 384 

Technic  of  Administration      .     .  386 

Signs  of  Anesthesia  and  Recovery  ...  387 

Indications  and  Contraindications 387 


CONTENTS  XVII 

Gexeral  Axesthetics — Cont'd.  vxge 

Ethyl  Chlorid 387 

Composition 387 

Effect  on  the  Organism 388 

Ether 388 

Composition 388 

Effect  on  the  Organism 388 

Cliloroform 388 

Composition 388 

Effect  on  tlie  Organism 389 

Local  Anesthesia 389 

Local  Anesthetics 392 

Cocain ,     ...  393 

Novocain 393 

Freezing 394 


ILLUSTRATIONS 


Fig.  Page 

1  Standard  forceps  No.  1 ,  12 

2  Standard  forceps  No.  2 12 

3  Standard  forceps  No.  3  R 13 

4  Standard  forceps  No.  3  L 14 

5  Standard  forceps  No.  4 15 

6  Standard  forceps  No.  5 15 

7  Standard  forceps  No.  6 17 

8  Standard  forceps  No.  7 18 

9  Standard  forceps  No.  8 19 

10  Standard  forceps  No.  9 20 

11  Standard  special  A  forceps 23 

12  Standard  special  B  forceps 24 

13  Author's  improved  Standard  forceps  No.  7 25 

14  Holding  the  forceps 26 

15  Straight-shank   elevator 30 

16  Curved-shank  elevator 31 

17  Knott  elevator 32 

18  Author's  lower  root  elevator,  Nos.  1  and  2 34 

19  Holding  the  author's  lower  root  elevator 35 

20  Author's  special  elevator,  Nos.  3  and  4 36 

21  Lecluse  elevator.  No.  1 37 

22  Holding  the  Lecluse  elevator 38 

23  Author's  modified  Lecluse  elevator,  No.  2 39 

24  Cryer  elevator,  Nos.  1  and  2 40 

25  Author's  modified  Cryer  elevator,  Nos.  3  and  4 40 

26  Holding  the  Cryer  elevator 41 

27  Morrison  reamer 42 

28  Long-shank  screw-porte,  with  handle 43 

29  Long-shank  screw-porte,  without  handle 43 

30  Short-shank  screw-porte,  without  handle 44 

31  Keith   screw-porte 44 

32  Derenberg  tweezers 45 

33  Lancet 45 

34  Curved   scissors 46 

35  Standard  syringe 47 

36  Bismuth  syringe 48 

37  Curet 49 

38  Allen  mouth-gag 50 

39  Wooden  wedge 51 

40  Retractor 52 

41  Mastoid  chisel       53 

42  Mouth  mirror 54 

43  Foil  carrier 54 

44  Explorer 55 

45  Probe 55 

XIX 


XX  ILLUSTRATIONS 

Fig.  Page 

46  An  almost  perfect  set  of  teeth — anterior  view 64 

47  Same  subject  as  Fig.  46 — side  view 65 

48  Same  subject  as  Figs.  46,  47 — view  of  superior  arch 66 

49  Same  subject  as  Figs.  46,  47,  48 — view  of  inferior  arch 66 

50  Superior  and  inferior  arcli — anterior  view,  sliowing  the  roots  of  the 

teeth       67 

51  Same  subject  as  Fig.  50 — side  view,  showing  the  roots  of  the  teeth  .     .  68 

52  Position  of  the  operator  when  applying  forceps  to  superior  teeth ...  95 

53  Position  of  the  operator  when  applying  forcepi;  to  Inferior  teeth  ...  97 

54  Types  of  superior  central  incisors 109 

55  Position  of  the  operator's  hands  when  applying  forceps  to  a  superior 

central  incisor 110 

56  Extraction  movements  for  superior  central  incisor 113 

57  Method  of  avoiding  the  use  of  the  lancet  where  the  gum   tissue  cov- 

ers the  root 117 

58  Straight-shank  elevator  applied  to  the   lingual  surface  of  a  superior 

central  incisor  root 119 

59  Types  of  superior  lateral  incisors 121 

60  Extraction  movements  for  superior  lateral  incisor 123 

61  Mesial  and  distal  application  of  forceps  to  a  superior  lateral  incisor 

completely  displaced  lingually 125 

62  Types  of  superior  cuspids 131 

63  Position  of  the  operator's  hands  when  applying  forceps  to  a  superior 

cuspid  on  the  left  side  of  the  arch 132 

64  Position  of  the  operator's  hands  when  applying  forceps  to  a  superior 

cuspid  on  the  right  side  of  the  arch 133 

65  Mesial  and  distal  application  of  forceps  to  a  superior  right  cuspid   .     .  134 

66  Extraction  movements  for  superior  cuspid 135 

67  Types  of  superior  first  and  second  bicuspids 141 

68  Position  of  the  operator's  hands  when  applying  forceps  to  a  superior 

bicuspid  on  the  left  side  of  the  arch 142 

69  Position  of  the  operator's  hands  when  applying  forceps  to  a  superior 

bicuspid  on  the  right  side  of  the  arch 143 

70  Extraction  movements  for  superior  first  and  second  bicuspids       .     .     .  145 

71  Superior  second  bicuspid  displaced  to  the  lingual  side  of  the  arch     .     .  148 

72  Cryer  elevator  applied  to  a  displaced  superior  second  bicuspid  ....  148 

73  Superior  first  bicuspid  with  crown  destroyed  by  caries 150 

74  Same  subject  as  Fig.  73 — roots  separated  by  caries 150 

75  Buccal  root  of  a  superior  first  bicuspid  displaced .  151 

76  Types  of  superior  first  and  second  molars 155 

77  Position  of  the  operator's  hands  when  applying  forceps  to  a  superior 

molar  on  the  left  side  of  the  arch 156 

78  Position  of  the  operator's  hands  when  applying  forceps  to  a  superior 

molar  on  the  right  side  of  the  arch 157 

79  Extraction  movements  for  superior  first  and  second  molars 160 

80  Types  of  superior  third  molars 171 

81  Types  of  abnormal  superior  third  molars 173 

82  Extraction  movements  for  superior  third  molar 175 

83  Impacted  superior  third  molar 179 

84  Impacted  superior  third  molar 180 

85  Impacted  superior  third  molar 181 


ILLUSTRATIONS  XXI 

Fig.  Page 

86  Types  of  inferior  central  and  lateral  incisors 185 

87  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

incisor 186 

88  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

incisor 187 

89  Extraction  movements  for  inferior  incisor 191 

90  Types  of  inferior  cuspids 197 

91  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

cuspid  on  the  right  side  of  the  arch 198 

92  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

cuspid  on  the  left  side  of  the  arch 199 

93  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

cuspid  on  the  right  side  of  the  arch 201 

94  Types  of  inferior  first  and  second  bicuspids 205 

95  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

bicuspid  on  the  left  side  of  the  arch 206 

96  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

bicuspid  on  the  right  side  of  the  arch 207 

97  Extraction  movements  for  inferior  first  and  second  bicuspids  ....  211 

98  Inferior  right  second  bicuspid  in  complete  lingual  displacement     .     .  211 

99  Same   subject   as  Fig.   98 — forceps   applied   to    inferior  right   second 

bicuspid  in  complete  lingual  displacement 211 

100  Inferior  first  bicuspid  root  weakened  by  caries 214 

101  Same  subject  as  Pig.  100 — Cryer  elevator  applied  for  extraction  .     .     .  214 

102  Root  of  an  inferior  first  bicuspid  wedged  between  the  two  adjacent 

teeth 216 

103  Same   subject   as   Fig.    102 — straight-shank    elevator   applied    for    ex- 

traction       217 

104  Method  of  using  a  bur  to  remove  a  small  part  of  a  root 219 

105  Types  of  inferior  first  and  second  molars 221 

106  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

molar  on  the  left  side  of  the  arch 222 

107  Position  of  the  operator's  hands  when  applying  forceps  to  an  inferior 

molar  on  the  right  side  of  the  arch 223 

108  Extraction  movements  for  inferior  first  and  second  molars 227 

109  Inferior  first  molar — distal  surface  destroyed  by  caries 230 

110  Inferior  second  molar — distal  surface  destroyed  by  caries 231 

111  Same  subject  as  Fig.  110 — application  of  the  Lecluse  elevator  for  ex- 

traction       232 

112  Crown  of  an  inferior  first  molar  destroyed  by  caries,  with  the  roots 

partially  united— application  of  the  elevator  to  separate  the  roots     .  235 

113  Same  subject  as  Fig.  112 — separating  the  roots 236 

114  Same  subject  as  Figs.  112,  113 — removing  the  distal  root 237 

115  Same  subject   as  Figs.   112,   113,   114 — removing  the  mesial   root  by 

mesial   application 238 

116  Forceps  applied  to  a  distal  root  of  an  inferior  first  molar 240 

117  Same  subject  as  Figs.  112,  113,  114,  115— removing  the  mesial  root  by 

distal    application 241 

118  Inferior  first  molar  affected  with  extensive  caries 243 

119  Same  subject  as  Fig.  118— showing  condition  of  the  hard  structure 

and  roots 243 


XXII  ILLUSTRATIONS 

Fig.  Page 

120  Method  of  separating  fractured  roots 245 

121  Author's  modified  Cryer  elevator  applied  to  a  fractured  inferior  sec- 

ond  molar 246 

122  Types  of  inferior  third  molars 249 

123  Types  of  inferior  third  molars 251 

124  Position  of  the  operator's  hands  when  applying  the  elevator  to  the 

left  side  of  the  arch 252 

125  Position  of  the  operator's  hands  when  applying  the  elevator  to  the 

right  side  of  the  arch , 253 

126  Decayed  third  molar  to  be  removed  with  the  elevator — teeth  anterior 

to  the  second  molar  missing 257 

127  Decayed  third  molar  to   be  removed   with   the  elevator — reinforcing 

the  second  molar  with  wood  block 258 

128  Decayed  third  molar  to  be  removed  with  the  elevator — inclination  of 

the  teeth  prevents  reinforcing  the  second  molar  with  wood  block  .  258 

129  Decayed  third  molar  to  be  removed  with  the  elevator — inserting  mod- 

eling compound  to  reinforce  the  second  molar 259 

130  Decayed  third  molar  to  be  removed  with  the  elevator — applying  the 

thumb  to  reinforce  the  second  molar 259 

131  Extraction  of  a  third  molar  with  the  elevator 260 

132  Same  subject  as  Fig.  131 — application  of  the  Lecluse  elevator  from 

the  buccal  side 261 

133  Application  of  the  author's  modified  Lecluse  elevator  on  the  left  side 

of  the  arch  from  a  position  on  the  right  side  of  the  patient  .     .     .  262 

134  Same  subject  as  Figs.  131,  132 — first  extraction  movement 264 

135  Same  subject  as  Figs.  131,  132,  134— second  extraction  movement  .     .  265 

136  Inferior  third  molar  completely  displaced  to  the  lingual  side  of  the 

arch 269 

137  Inferior  third  molar  completely   displaced  to  the  buccal  side  of  the 

arch 271 

138  Isolated  inferior  third  molar 280 

139  Same  subject  as  Fig.  138 — application  of  author's  lower  root  elevator 

for  extraction 280 

140  Isolated  inferior  third  molar,  with  the  crown  destroyed  by  caries  .     .  281 

141  Same  subject  as  Fig.  140 — application  of  the  author's  lower  root  ele- 

vator for   extraction Z81 

142  Same  subject  as  Figs.  140,  141 — tooth  partly  delivered  from  its  socket  .  281 

143  Dry  specimen  of  two  partially  impacted  inferior  third  molars     .     .     .  288 

144  Model  of  a  partially  impacted  inferior  third  molar 289 

145  Radiograph  of  a  partially  impacted  inferior  third  molar 290 

146  Partially  impacted  inferior  third  molar 291 

147  Same  subject  as  Fig.  146 — application  of  the  Lecluse  elevator  for  ex- 

traction      291 

148  Radiograph  of  a  partially  impacted  inferior  third  molar 292 

149  Radiograph  of  a  partially  impacted  inferior  third  molar 292 

150  Partially  impacted  inferior  third  molar 293 

151  Model  of  a  partially  impacted  inferior  third  molar 293 

152  Method  of  removing  the  contact  point  from  an  impacted  third  molar 

with  a  cross-cut  saw 294 

153  Radiograph  of  an  impacted  inferior  third  molar 295 

154  Radiograph  of  an  impacted  inferior  third  molar 297 


ILLUSTRATIONS  XXIII 

Fig.  Page 

155  Radiograph  of  an  impacted  inferior  third  molar 297 

156  Radiograph  of  an  impacted  inferior  third  molar 298 

157  Radiograph  of  a  completely  impacted  inferior  third  molar 300 

158  Radiograph  of  a  completely  impacted  inferior  third  molar 301 

159  Radiograph  of  a  completely  impacted  inferior  third  molar 302 

160  Impacted  inferior  third  molar 302 

161  Radiographs  of  impacted  inferior  third  molars 302 

162  Impacted  inferior  third  molar — application  of  the  Lecluse  elevator  for 

extraction 303 

163  Radiographs  of  impacted  inferior  third  molars 304 

164  Impacted    inferior   third    molar — inserting    the    bur    to    remove    the 

process 305 

165  Impacted  inferior  third  molar 305 

166  Impacted  inferior  third  molar 306 

167  Same  subject  as  Fig.  166 — incision  of  the  gum  to  expose  the  process   .  306 

168  Same  subject  as  Figs.  166,  167 — the  hard  tissue  burred  from  under  the 

impacted  molar 307 

169  Radiographs  of  completely  impacted  inferior  third  molars 308 

170  Radiographs  of  impacted  inferior  third  molars 309 

171  Radiograph  and  model  of  impacted  inferior  third  molars 310 

172  Radiographs  of  impacted  inferior  third  molars 311 

173  Impacted  third  molars 312 

174  Models  of  impacted  third  molars 313 

175  Completely  impacted  third  molar — making  an  incision   with  curved 

scissors  into  the  gum  tissue 314 

176  Same  subject  as  Fig.  175 — the  process  being  removed 314 

177  Same   subject  as  Figs.  175,  176 — extent  to  which  the  process  is  re- 

moved before  applying  the  elevator 315 

178  Same  subject  as  Figs.  175,  176,  177 — application  of  the  Lecluse  ele- 

vator for  extraction 315 

179  Types  of  supernumerary  teeth 320 

180  Model  showing  a  supernumerary  tooth  occupying  the  position  of  the 

superior  right  lateral  incisor 321 

181  Fusion  of  a  supernumerary  tooth  with  a  bicuspid 321 

182  Superior  left  molar  with  a  supernumerary  tooth  projecting  from  the 

lingual  root 322 

183  Types  of  hypercementosed  teeth 324 

184  Radiograph  of  a  hypercementosed  inferior  second  bicuspid     ....  325 

185  Lower  third  molar  with  foraminal  arrangement  of  roots  due  to  hy- 

percementosis 328 

186  Teeth  with  fused  roots 338 

187  Fracture  of  the  alveolar  process 354 

188  Exposed  process 356 

189  Dilatation  of  the  socket 357 

190  Same  subject  as  Fig.   189 — applying  the  thumb  and   index  finger  to 

correct  a  dilated  socket 358 

191  Radiographs  of  teeth  showing  the  effect  of  chronic  septic  pericemen- 

titis   366 


EXODONTIA 


CHAPTER  I. 

HISTORICAL. 

By  a  natural  process  of  reasoning,  based  on  data  of  human 
anatomy  and  physiology,  it  is  fair  to  conclude  that  diseases  of  the 
teeth  and  the  involvement  of  contiguous  parts  had  their  origin 
with  the  beginning  of  the  human  race,  and  it  is  to  be  presumed 
that  relief  was  sought  for  the  pain  resulting  from  a  diseased  con- 
dition of  a  tooth.  It  is  not  known  what  remedies  or  appliances 
may  have  been  used  in  prehistoric  times  in  an  endeavor  to  render 
this  relief,  but  in  the  course  of  time  history  began  to  record  the 
efforts  that  were  made  to  allay  the  pain  caused  by  dental  defects. 

As  in  cases  of  various  ailments  of  the  human  form  in  early 
ages  the  sacerdotal  or  priestly  class,  whose  claim  to  mystic  pow- 
ers dominated  primitive  people,  administered  both  local  and  gen- 
eral medicaments  and  executed  incantations  for  the  relief  of 
bodily  pain,  it  is  very  probable  that  the  relief  of  pain  from  defec- 
tive teeth  was  included  in  their  practice  of  mysterious  remedial 
ceremonies.  This  custom  of  sacerdotal  treatment  continued 
until  the  advancement  of  civilization  developed  physicians  and 
surgeons,  some  of  whom  practiced  the  treatment  of  teeth  as  a 
part  of  their  calling  until  dentistry  became  a  separate  profession. 

There  is  no  record  as  to  when  the  extraction  of  teeth,  either  by 
drawing  or  other  forcible  method  of  ejection,  may  have  been  in- 
troduced as  a  method  of  relief  from  suffering.  It  was  customary 
in  ancient  times  to  deposit  surgical  and  other  instruments  of 
practical  utility  in  certain  temples,  and  it  is  recorded  that  leaden 
forceps  were  found  in  the  temple  of  Apollo  at  Delphi,  which  indi- 
cates that  this  structure  was  used  as  an  archive  for  such  instru- 
ments in  various  arts  as  were  to  be  preserved  for  the  study  of 
posterity.     While  this  instrument  is  referred  to  as  forceps,  they 


2  HISTORICAL 

were  in  all  23robability  shaped  more  in  the  form  of  short-jawed 
tongs.  It  is  evident  that  only  very  loose  teeth  could  be  extracted 
with  such  forceps,  and  it  has  been  contended  b}^  some  writers 
that  these  forceps  were  only  a  model,  the  original  instrument 
being  constructed  of  stronger  material. 

When,  however,  it  is  considered  that  various  medicaments 
were  at  that  time  applied  to  the  affected  tooth  and  gums  with  the 
object  of  softening  the  surrounding  tissue  and  thereby  loosening 
the  tooth  before  extraction,  it  is  probable  that  the  leaden  forceps 
in  the  temple  of  Apollo  were  of  sufficient  stability  to  serve  the 
purpose  of  extracting  the  loosened  tooth.  Application  of  sul- 
phur, pepper,  and  roasted  and  pulverized  spines  or  "stings"  of 
the  trygon  fish  were  often  utilized  in  the  loosening  process,  and 
great  importance  appears  to  have  been  attached  to  these  pre- 
liminaries. Tissue  not  previously  destroyed  by  scurvy  or  other 
affection  was  scrajjed  from  the  tooth,  its  attachment  broken  by 
concussion,  and  the  tooth  finally  removed  with  the  fingers  or 
leaden  forceps  similar,  no  doubt,  to  those  found  in  the  temple. 
In  fact,  in  some  cases  the  normal  gum  and  integument  were  ex- 
cised from  an  affected  tooth  to  such  an  extent  that  the  root  was 
exposed,  when  the  tooth  could  be  removed.  To  prevent  the  prob- 
able fracture  of  a  carious  tootli,  the  cavity  was  filled  with  lint, 
wood  fiber,  or  lead  to  better  withstand  the  pressure  of  the  forceps. 
It  was  held  that  the  operation  of  extraction  should  be  attempted 
only  after  all  known  remedial  agents  had  failed,  and  that  even 
the  extreme  measure  of  applying  the  red-hot  iron  should  first  be 
tried. 

CHRONOLOGICAL  DEVELOPMENT. 

Hippocrates  (B.  C.  400-357),  the  celebrated  Greek  physician, 
is  reported  to  have  been  the  first  writer  to  mention  the  exti-action 
of  teeth.  He  is  credited  with  the  statement  that  such  extraction 
was  a  simple  and  easy  operation,  but  was  contradicted  by  other 
authorities,  who  declared  that  the  operation  was  a  serious  under- 
taking and  sometimes  resulted  fatally. 

Claudius  Galen  (130-218),  an  Italian  physician,  was  of  the  opin- 
ion that  the  leaden  forceps  found  in  the  temple  of  Apollo  were 
intended  for  the  extraction  of  loose  teeth,  and  expressed  the  be- 
lief that,  if  such  an  instrument  were  to  be  used  for  the  extraction 
of  teeth  that  were  tightly  fixed,  it  would  be  made  of  stronger 


CHRONOLOGICAL  DEVELOPMENT  3 

material.  Galen,  who  gave  a  great  deal  of  attention  to  the  treat- 
ment of  the  teeth,  ditl  not  attach  much  importance  to  extraction, 
and  was  more  concerned  about  the  application  of  remedies  to 
cause  the  loosening  and  hnal  falling  out  of  the  tooth. 

Abulcasis  (1050-11:^2),  an  Arabian  surgeon,  who  was  very 
much  interested  in  matters  pertaining  to  the  teeth,  scarified  the 
tissue  surrounding  the  tooth  to  be  extracted,  laid  bare  the  root, 
endeavored  to  loosen  the  tooth,  and  then  undertook  to  extract 
the  tooth  with  what  has  been  referred  to  as  forceps.  If,  however, 
the  extraction  could  not  be  accomplished  with  these  forceps,  he 
would  apply  an  elevator-shaped  instrument  under  the  tooth  and 
force  it  out  in  that  manner,  which  indicates  that  the  principle  of 
the  elevator  was  employed  during  the  middle  ages. 

John  Gaddesden  (1311),  an  English  physician,  would  extract  a 
tooth  only  after  his  various  medicaments — such  as  powdered 
dried  dung,  brain  of  the  hare,  green  frog's  fat,  etc. — and  even 
the  red-hot  iron  had  failed  to  give  relief.  He  would  then  loosen 
the  gum  surrounding  the  root,  and  extract  the  tooth  with  the 
forceps.  Li  some  cases  he  would  force  out  the  tooth  with  an 
elevator-shaped  instrument,  whose  blade  was  flat  on  one  side 
and  convex  on  the  other,  with  a  sharp  edge,  very  much  resem- 
bling in  this  respect  some  of  the  types  of  elevators  used  at  the 
present  time. 

Ambroise  Pare  (1517-1592),  a  French  surgeon,  who  brought 
the  art  of  surgery  up  to  a  standard  not  previously  attained,  de- 
voted considerable  space  in  his  writings  to  the  treatment  of  den- 
tal affections.  He  claimed  that  a  tooth  should  not  be  extracted 
until  the  pain  was  unbearable  and  all  medicaments  had  failed  to 
give  relief,  and  directed  that  in  case  of  a  cavity  it  should  be  filled 
with  linen  cloth  or  lead  to  prevent  fracture. 

Among  the  earlier  instruments  employed  for  the  removal  of 
teeth  were  the  pelican,  lever,  goatsfoot,  ravensbill,  storksbill,  and 
key.  There  is  some  doubt  as  to  the  writer  who  first  mentioned 
the  use  of  the  pelican,  an  instrument  of  peculiar  construction, 
made  from  time  to  time  in  a  number  of  modified  forms,  but  all  on 
the  same  principle,  diiferent  authorities  ascribing  the  first  refer- 
ence to  the  instrument  respectively  to  Ambroise  Pare,  French 
surgeon;  to  Peter  Foreest,  Dutch  surgeon;  and  to  Walter  Kyff, 
German  surgeon.  All  of  these  surgeons  lived  at  different  periods 
from  1500  to  1597,  and  were  largely  interested  in  the  treatment 


4  HISTORICAL 

of  teeth.  Some  authorities,  however,  give  credit  for  the  intro- 
duction of  the  pelican  to  Giovanni  d'Arcoli,  an  Italian  surgeon, 
who  died  in  1484,  a  number  of  years  before  the  birth  of  any  of 
the  three  surgeons  named. 

Croissant  de  Garengeot  (1688-1759),  a  French  surgeon,  was  for 
a  long  time  considered,  particularly  by  the  French  surgical  pro- 
fession, as  the  inventor  of  the  key,  but  it  appears  that  this  instru- 
ment was  used  in  Germany  before  the  time  of  Garengeot,  beuig 
known  as  the  German  key,  and  that  de  Garengeot,  as  well  as 
Frere  Come,  another  French  surgeon,  simply  improved  the  in- 
strument in  some  respects.  Previous  to  their  time  the  instru- 
ment was  known  as  the  German  key. 

John  Aitkin  (1771),  an  English  surgeon,  made  some  further 
improvements  on  the  key,  which  was  subsequently  referred  to  as 
the  English  key. 

The  key  was  an  improvement  over  all  instruments  that  had 
preceded  it,  and  was  generally  conceded  to  be  a  great  step  for- 
ward as  an  instrument  for  extraction.  Benjamin  Bell  declared 
himself  in  favor  of  its  use  in  the  extraction  of  molars  and  bicus- 
pids, especially  of  those  of  the  inferior  arch,  recommending  the 
key  as  the  only  instrument  to  be  depended  upon  when  the  forceps 
were  found  inefficient.  There  were,  as  stated,  several  forms  of  the 
key,  but  all  constructed  on  the  same  general  principle,  which  con- 
sisted of  a  shaft  with  a  handle,  interchangeable  hooks  for  grip- 
ping the  tooth,  and  a  flat  bar  or  bolster  to  rest  against  the  gum 
and  alveolar  process,  both  of  the  latter  acting  as  a  fulcrum  when 
the  instrument  was  applied  to  the  tooth.  Its  use  caused  contu- 
sion and  laceration  of  the  soft  tissues,  often  fractured  the  outer 
plate  of  the  alveolus,  and  resulted  in  many  disagreeable  and 
serious  accidents. 

Pierre  Fauchard  (1690-1761),  a  French  dentist,  placed  the  art 
of  dentistry  on  a  higher  plane  by  introducing  a  systematic  treat- 
ment of  the  teeth,  and  was  instrumental  in  removing  many  of  the 
former  prejudices  and  unscientific  beliefs,  particularly  the  super- 
stition that  the  extraction  of  teeth  was  dangerous  to  the  eyes 
and  other  organs  of  the  head.  He  also  recommended  the  use  of 
variously  shaj^ed  instruments  for  the  extraction  of  the  different 
teeth. 

Lecluse  (1754)  invented  an  elevator  specially  designed  for  the 
extraction  of  the  lower  third  molar,  and  a  modification  of  this 


CHRONOLOGICAL  DEVELOPMENT  5 

elevator  is  in  use  at  the  present  time,  being  considered  a  very- 
serviceable  instrument,  but  the  scope  of  its  utility  has  extended 
the  use  of  the  instrument  beyond  its  sole  application  to  the  infe- 
rior third  molar.  As  early  as  the  time  of  Abulcasis  (1050-1122) 
crude  forms  of  elevators  were  used  for  the  purpose  of  extracting 
the  roots  of  teeth. 

Joseph  Serre  (1759-1830),  a  dentist  of  Belgian  birth,  but  whose 
professional  activities  were  pursued  in  Germany,  invented  vari- 
ous extracting  instruments,  the  one  deserving  special  mention 
being  the  conical  screw  for  the  extraction  of  roots  hollowed  out 
by  caries,  an  instrument  which,  in  a  modified  form,  is  used  at  the 
present  time. 

From  the  time  of  the  introduction  of  the  key,  efforts  were  made 
by  various  persons  engaged  in  dentistry  to  invent  an  instrument 
with  which  a  tooth  could  be  readily  extracted  in  a  manner  involv- 
ing less  danger  of  fracture  to  the  tooth  and  injury  to  the  sur- 
rounding parts.  Instruments  to  answer  the  purpose  of  forceps, 
but  in  the  shape  of  tongs,  with  short,  rounded  jaws  and  handles 
of  convenient  length,  were  made  for  the  extraction  of  teeth,  but 
were  as  a  rule  impracticable,  as  they  were  too  crude  and  bulky. 
The  operator  was  compelled  to  have  these  so-called  forceps  made 
in  the  rough  and  then  shape  them  as  well  as  he  could  to  his  idea 
of  adaptability. 

The  methods  and  appliances  heretofore  described  for  extract- 
ing teeth  prevailed,  with  immaterial  changes  from  time  to  time, 
until  Sir  John  Tomes  (1840),  an  English  dentist,  originated  the 
''anatomical  forceps,"  devising  a  separate  pair  for  each  tooth 
and  for  each  side  of  the  arch,  and  were  so  constructed  as  to  tit 
respectively  the  various  shapes  of  the  different  teeth.  These 
forceps  were  first  used  by  Tomes  in  Middlesex  Hospital,  and 
proved  to  possess  such  great  advantages  that  they  were  freely 
copied  and  used,  to  the  exclusion  of  all  other  tongs  or  forceps. 
Because  Tomes'  forceps  gave  such  security  and  ease  to  the 
operation,  there  followed  an  era  of  promiscuous  "tooth-pulling," 
country  doctors,  barbers,  and  even  village  blacksmiths  purchas- 
ing and  using  the  forceps,  as  the  pseudo-operators  as  well  as  the 
patients  were  ignorant  of  the  possibility  of  preserving  the  teeth. 

Tomes  was  not,  however,  given  credit  for  his  invention,  which 
gave  rise  to  a  controversy,  whereupon  he  in  1848  reissued  his 
treatise  on  "Dental  Physiology  and  Surgery"  for  the  express 


6  HISTORICAL 

purpose  of  establishing  his  priority,  in  which  he  states  that, 
"after  a  lapse  of  seven  years,  the  instruments  in  question  have 
come  into  general  use,  whereas  previous  to  his  first  paper,  June 
4,  1841,  they  had  no  such  instruments."  These  instruments 
came  into  universal  use,  and  our  present  forceps  are  only  modi- 
fications of  the  original  "Tomes"  forceps,  with  the  beaks  and 
handles  greatly  changed,  but  retaining  the  principle  of  the  beaks 
fitting  the  neck  of  a  tooth.  The  forceps  of  modern  construction 
are  made  of  the  finest  steel,  wrought  in  perfect  form  and  finish, 
with  different  shapes  of  handles  and  beaks,  the  handles  con- 
forming closely  to  the  hands  of  the  operator  and  the  beaks 
following  the  shapes  of  the  different  teeth. 

PROGRESS  OF  MODERN  METHODS. 

Sterilization  was  unknown  to  pioneer  dental  operators,  and 
it  is  related  that  blood  was  permitted  to  dry  on  the  instruments 
repeatedly  in  order  that  their  appearance  of  being  much  used 
might  testify  to  the  exi)erience  of  the  oi:)orator.  The  introduc- 
tion of  the  principles  of  antiseptic  surgery  by  Lister  in  18G7 
improved  the  condition  under  which  the  operations  were  per- 
formed, and  greatly  reduced  the  ratio  of  infection  resulting 
from  extractions. 

Modern  dentistry  has  done  much  in  developing  methods  for 
restoring  teeth  to  such  condition  that  they  may  again  serve,  so 
far  as  conditions  will  permit,  the  purpose  for  which  they  were 
intended,  and  the  experience  and  knowledge  of  the  operator 
must  determine  the  procedure  to  be  followed  in  any  individual 
case.  Many  factors  nnist  ha  considered  by  the  operator  in 
reaching  a  conclusion,  and  tlie  attending  circumstances  of  a 
case  will  naturally  govern  his  decision.  It  is  now  generally 
admitted  that  it  is  not  good  practice  to  sacrifice  a  tooth  that  can 
be  restored,  as  artificial  teeth,  though  more  scientifically  made 
than  formerly,  do  not  approximate  the  function  of  the  natural 
teeth.  The  first  step,  therefore,  in  any  procedure  is  a  thorough 
examination  of  the  existing  conditions,  embracing  the  tooth  to 
be  operated  upon  and  the  surrounding  structures,  and  ascer- 
taining their  condition  as  accurately  as  ]wssible.  Tf  there  is 
doubt  in  the  mind  of  the  operator  as  to  which  tooth  is  involved, 
visible  pathologic  conditions  and  the  sensations  of  the  patient 
not  making  this  point  clear,  recourse  should  be  had  to  radiog- 


PROGRESS  OF  MODERN  METHODS  7 

rapliy.  It  may  sometimes  be  advisable  to  withhold  judgment, 
and  treat  the  symptoms  for  a  time  in  order  that  the  pathologic 
conditions  may  become  more  apparent,  but,  if  the  diagnosis  is 
clear  and  extraction  is  indicated,  the  patient  should  b^  advised 
accordingly. 

The  patient  who  places  himself  in  the  hands  of  the  operator 
for  an  extraction  desires  the  operation  to  be  accomplished  surely, 
quickly,  and  ])ainlessly,  but  will  forego  "quickly"  for  "surely 
and  painlessly,"  and,  in  turn,  will  sacrifice  "quickly  and  pain- 
lessly" for  "surely."  The  operator  who  can  successfully  com- 
bine these  three  factors  will  ever  find  his  reputation  growing  in 
popularity  and  his  patients  increasing  in  number.  To  accom- 
plish this  desideratum  requires,  among  other  attainments,  a 
thorough  knowledge  of  the  anatomy,  histology,  and  pathology 
of  the  parts  involved.  This  knowledge  may  be  obtained  from 
text-books  devoted  to  these  subjects  and  by  close  observation 
of  all  cases  coming  under  the  operator's  hands.  As  complete  a 
history  as  possi1)le  should  be  elicited  from  the  patient,  for  much 
valual)le  data  can  thus  be  obtained,  not  only  to  form  the  diag- 
nosis of  that  particular  case,  but  to  aid  in  the  judgment  to  be 
exercised  in  future  cases. 

"Within  the  last  half  century  the  science  of  dentistry  has 
progressed  very  rapidly,  and  the  restoration  of  teeth  by  filling 
and  crowning  has  decreased  the  number  of  operations  of  extrac- 
tion that  would  otherwise  take  place.  Progress  in  the  field  of 
exodontia  has  been  in  keeping  with  the  advances  made  in  other 
departments  of  dentistry,  and  teeth  are  no  longer  extracted 
promiscuously.  When  extraction  is  determined,  the  tooth  is 
usually  affected  by  some  ]:>athologic  condition  involving  the 
associated  tissues  that  will  not  yield  to  treatment,  or  is  so  exten- 
sively decayed  that  it  is  impossible  to  restore  it  to  a  condition 
of  future  usefulness.  The  general  public  has  also  learned  to 
care  for  the  teeth,  and  is  now  demanding  their  restoration 
whenever  possible.  When,  however,  extraction  can  no  longer 
be  postponed,  the  operator  should  exercise  tact  and  skill,  as  the 
average  patient  submits  to  such  an  operation  with  apprehension, 
and,  should  the  patient  suffer  much  pain  or  should  the  tooth  be 
fractured  during  its  removal,  the  operator  is  liable  to  be  severely 
censured.  If,  on  the  other  hand,  the  operation  is  successful,  the 
operator  will  receive  the  commendations  of  the  patient. 


CHAPTER  II. 
INSTRUMENTS. 

In  considering  the  extraction  of  teetli  as  an  operative  pro- 
cedure, it  is  assumed  that  the  reader  is  familiar  with  the 
anatomy,  histology,  and  physiology  of  the  teeth.  The  proper 
selection  of  instruments  for  the  operative  procedure  is  an  im- 
l^ortant  matter,  and  a  judicious  choice  should  be  made,  as  a 
great  deal  depends  on  the  kind  of  instruments  available  for  an 
operation.  The  essential  ones  are  not  numerous,  and  a  few  well 
selected  are  to  be  j^referred  to  a  larger  number  improperly 
chosen. 

FORCEPS. 

The  forceps  are  the  principal  instruments  for  extracting,  and 
are  used  more  frequently  than  any  other  instrument  designed 
for  this  operation.  Their  use  is  indicated  where  the  tooth  to  be 
extracted  is  so  situated  in  relation  to  the  other  teeth  and  the 
tissues  of  the  mouth  as  to  permit  their  free  application,  and, 
wherever  indicated,  a  more  accurate  adaptation,  better  leverage, 
and  a  more  nearly  perfect  control  are  to  be  had  with  them  than 
with  other  instruments.  As  success,  in  so  large  a  degree,  is 
dependent  on  the  forceps,  their  construction  should  be  such  as 
to  be  of  the  greatest  possible  utility.  Painful  accidents  so  fre- 
quently occur  from  the  use  of  improperly  constructed  forceps 
that  no  operation  should  be  attempted  with  any  of  that  char- 
acter. The  operator  should  choose  a  well-selected  set,  and  learn 
to  operate  exclusively  with  them,  as  by  this  course  he  not  only 
lessens  the  possibility  of  accidents,  but  by  becoming  accustomed 
to  certain  instruments  he  greatly  increases  his  skill  as  an 
exodontist,  for  it  is  only  by  the  frequent  use  of  an  instrument 
that  dexterity  in  its  manipulation  can  be  acquired.  The  com- 
ponent parts — beaks,  joint,  and  handles — should  be  made  of 
the  best  steel,  and  tempered  to  witlistand  any  strain,  without 
bending  or  breaking,  that  may  be  placed  on  them. 

The  beaks  should  be  so  constructed  that  thev  fit  the  neck  of 


FORCEPS  9 

the  tooth  for  which  they  are  intended,  so  that,  when  adjusted,  a 
firm  grip  of  the  tooth  is  obtained.  The  ends  of  the  beaks  should 
be  thin  enough  to  permit  insertion  under  the  free  margin  of  the 
gum,  by  pressing  it  aside,  without  causing  any  considerable 
contusion  of  these  tissues,  and  their  edges  should  be  sharp 
enough  to  cut  through  the  alveolar  process  when  it  becomes 
necessary.  The  beaks  should  be  canted  at  such  an  angle  to  the 
handles  that  they  can  be  applied  to  the  tooth  in  line  with  its 
long  axis,  and  so  curved  that,  when  pressure  is  applied,  the 
curvature  will  aid  in  loosening  the  tooth.  The  instrument,  in 
all  its  parts,  should  be  of  a  size  that  will  permit  a  free  execution 
of  the  extraction  movements,  the  lifting  of  the  tooth  from  its 
socket,  and  its  final  conveyance  from  the  oral  cavity. 

The  joint  should  have  just  enough  free  play  to  allow  an  easy 
opening  and  closing  of  the  beaks  without  permitting  any  lost 
motion.  The  edges  of  the  joint  should  be  made  in  such  a  manner 
that  the  lips  or  other  soft  tissues  cannot  be  caught  between  them 
while  operating.  Some  of  the  English  and  German  forceps  are 
ideal  in  this  resj^ect,  having  joints  with  well-rounded  edges, 
while  in  the  American  type  the  edges  are  usually  so  sharp  and 
come  together  so  close  that  there  is  always  danger  of  tissue 
laceration.  This  danger  is,  however,  readily  overcome  by  round- 
ing off  its  edges  with  a  carborundum  stone,  which  does  not 
impair  the  strength  of  the  joint  or  affect  the  usefulness  of  the 
forceps. 

As  the  proper  adaptation  of  the  handles  to  the  hand  is  very 
important  in  securing  a  firm  grasp,  maintaining  steadiness,  and 
applying  proper  leverage,  it  is  advisable  to  have  them  conform 
as  far  as  possible  to  the  hand  of  the  individual  operator,  who 
soon  learns  which  style  of  handles  is  best  suited  to  his  hand  and 
how  to  manipulate  them  to  the  best  advantage.  For  the  six 
superior  anterior  teeth  the  handles  of  the  forceps  should  be 
straight,  with  broad,  flat  surfaces.  For  the  superior  bicuspids 
the  handles  should  be  of  the  same  shape,  but  the  beaks  should  be 
set  about  three-quarters  of  an  inch  out  of  line  with  the  axis  of 
the  handles,  giving  the  beaks  the  characteristic  bayonet  shape. 
The  sui3erior  molar  forceps  have  the  same  sha])ed  handles,  and 
tlie  beaks  are  set  in  the  same  relation  to  them  as  are  the  beaks  of 
the  bicuspids.  All  the  superior  forceps  should  have  swell-end 
handles  to  prevent  bruising  the  palm  when  the  hand  is  passed 


10  INSTRUMENTS 

over  them  in  the  upward  pressure  when  such  pressure  becomes 
necessary.  For  the  inferior  teeth  the  handles  have  a  different 
shape,  that  part  which  fits  into  the  palm  of  the  hand  being- 
curved  and  turned  on  its  axis,  so  as  to  conform  to  the  anatomical 
shape  of  the  palm.  One  of  the  handles  is  shorter  than  the  other, 
but  with  the  same  form,  except  that  near  the  end  it  is  bent 
outward,  so  as  to  curve  over  the  little  lin,i>er,  thus  permitting 
the  ready  opening  of  the  forceps  without  allowing  them  to  slip 
through  the  hand. 

As  a  large  variety  of  forceps  is  manufactured,  each  having 
some  special  feature,  a  full  description  of  all  would  only  confuse. 
In  order  to  simplify  matters  and  make  their  selection  practical, 
the  set  of  Standard  forceps  has  been  taken  as  a  basis  for  illus- 
tration and  description.  These  forceps  were  selected  because 
they  approach  the  broadest  range  of  usefulness,  and  because 
they  have  no  superior  in  point  of  mechanism  and  general  titness. 
The  number,  limited  to  ten,  comprises  a  minimum  equipment, 
and  at  the  same  time  is  sufficient  for  the  usual  cases  in  which 
forceps  are  indicated.  In  rare  instances  special  forceps  prove 
serviceable,  and  such  as  are  needed  are  also  described. 

Forceps  for  Superior  Teeth. — For  the  su])erior  teeth  the  fol- 
lowing six  forceps  are  necessary: 

One  straight  forceps  for  the  central  and  lateral  incisors  and 
cuspids. 

One  bayonet-shaped  forceps  for  the  l)icuspids  and  molar  roots. 

Two  molar  forceps  (right  and  left)  for  the  first  and  second 
molars. 

One  third  molar  forceps,  ap))li('al)le  to  l)otli  sides  of  the  arch. 

One  superior  root  forceps  for  very  small  roots. 

Fig.  1  shows  the  forceps  designed  for  the  superior  central  and 
lateral  incisors  and  cuspids,  known  as  Standard  forceps  No.  1. 
The  beaks  are  alike  and  are  convex  in  their  transverse  diameter 
on  the  outer  surface,  which  curvature  ])roduces  sharp  cutting 
edges,  and  longitudinally  they  taper  and  terminate  in  rounded 
ends  that  closely  approximate  the  contour  of  the  necks  of  the 
teeth  for  which  they  are  designed.  Tn  cases  where  time  is  an 
important  factor  and  access  can  be  had  to  the  posterior  teeth, 
all  the  superior  teeth  may  l)e  extracted  with  these  forceps,  pro- 
vided the  crowns  of  the  molar  teeth  are  broken  down  so  as  to 
separate  the  roots  and  these  roots  are  not  too  firmly  attached. 


FORCEPS  FOR  SUPERIOR  TEETH  11 

Fig.  2  shows  tlie  forceps  designed  for  the  superior  bicuspids, 
known  as  Standard  forceps  No.  2.  They  are  also  applicable  to 
superior  molar  roots.  The  beaks  are  alike,  and  of  the  same 
shape  as  those  shown  in  Fig.  1,  but  narrower.  They  may  be 
used  also  on  the  lateral  incisors  when  displaced  or  broken  down, 
and  the  narrowed  space  does  not  j^ermit  the  regular  incisor 
forceps  to  be  used.  When  operating  under  a  general  anesthetic, 
with  the  intention  of  extracting  a  number  of  teeth,  this  instru- 
ment can  often  be  used  to  advantage  instead  of  Standard  forceps 
No.  1  for  the  extraction  of  the  anterior  teeth,  and  also  for  the 
removal  of  the  roots  of  all  the  superior  molars  and  the  molars 
themselves  when  attachment  is  not  too  firm. 

Figs.  3  and  4  show  the  forceps  designed  for  the  superior  first 
and  second  molars,  known  respectively  as  Standard  forceps 
No.  3  R  and  No.  3  L.  The  beaks  are  ba.yonet-shaped,  with  their 
outer  surfaces  convex.  The  inner  surface  of  the  palatal  beak 
is  concave,  and  the  beak  terminates  in  a  broad,  oval  point,  which 
is  rather  thin  and  sharp.  The  buccal  beak  has  a  concavo-concave 
inner  surface,  which  brings  the  end  of  the  beak  to  a  decided 
point,  and  the  outer  surface  is  of  such  bevel  as  to  make  the  point 
sharp.  This  point  fits  snugly  into  the  space  between  the  buccal 
roots  of  normal  teeth,  for  which  it  was  designed,  and  is  the 
distinguishing  feature  of  superior  molar  forceps.  Where  there 
is  reason  to  conclude  that  there  may  be  considerable  resistance, 
which  is  frequently  experienced  with  the  first  molar,  these 
forceps  should  always  be  used,  as  their  shape  is  such  that  the 
pressure  apj)lied  with  them  to  the  tooth  acts  as  a  powerful  force 
in  releasing  it  and,  in  a  measure,  overcomes  any  unusual  resist- 
ance that  may  be  encountered. 

Fig.  5  shows  the  forceps  designed  for  the  superior  third 
molars,  known  as  Standard  forceps  No.  4.  They  are  the  same 
shape  as  Standard  forceps  No.  3  E  and  No.  3  L,  except  that  the 
two  beaks  are  uniform  and  narrower.  The  narrowed  buccal  wall 
of  the  superior  third  molar,  due  to  the  absenceof  one  of  the  buccal 
roots  or  the  fused  condition  of  these  roots,  often  makes  the  appli- 
cation of  the  pointed  beak  of  the  regular  molar  forceps  imprac- 
ticable and  unsafe.  The  same  is  true  of  the  first  and  second 
molars  when  in  like  condition.  These  forceps  are  also  very 
practical  when  operating  under  a  general  anesthetic  and  ex- 
tracting all  the  superior  molars,  especially  where  the  alveolar 


12 


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16  INSTRUMENTS 

process  is  weakened  by  caries  or  the  teeth  are  not  too  firmly 
attached. 

Fig.  6  shows  the  forceps  designed  for  the  superior  roots,  known 
as  Standard  forceps  No.  5.  They  resemble  Standard  forceps 
No.  1,  except  that  they  are  lighter  in  general  construction,  the 
beaks  are  longer  and  narrower  and  are  slightly  curved  in  their 
mesio-distal  axis,  which  allows  their  application  to  roots  situated 
more  distally  than  can  be  reached  with  the  straight-beak  forceps, 
while  the  narrow  beaks  permit  them  to  be  applied  to  roots  that 
are  wedged  between  adjacent  teeth  or  to  small  roots  that  are 
situated  under  the  gum  margin.  Indeed,  these  forceps  are  indis- 
pensable in  some  cases — especially  where  the  two  small  roots  of 
the  superior  first  bicuspids  are  separated  by  decay  or  fracture. 

Forceps  for  Inferior  Teeth. — For  the  inferior  teeth  the  fol- 
lowing four  forceps  are  necessary: 

One  forcejDS  for  central  and  lateral  incisors,  cuspids,  bicuspids, 
and  all  inferior  molar  roots,  applicable  to  both  sides  of  the  arch. 

One  molar  forceps,  applicable  to  both  sides  of  the  arch. 

Two  forceps  for  the  ten  anterior  teeth,  commonly  known  as 
hawksbill  forceps. 

Fig.  7  shows  the  forceps  designed  for  the  ten  inferior  ante- 
rior teeth  and  inferior  molar  roots,  known  as  Standard  forceps 
No.  6.  They  are  applicable  for  the  extraction  of  the  ten  inferior 
anterior  teeth  when  space  will  permit  their  free  application,  and 
are  also  used  for  extracting  molar  roots.  The  beaks  are  set  at 
an  obtuse  angle  to  the  handles  and  curved  downward.  They  are 
narrow,  convex  on  the  outer  surface  and  concave  on  the  inner 
surface,  presenting  sharp  cutting  edges  and  terminating  in  nar- 
row, oval-like  points.  These  beaks  differ  in  a  general  way  from 
the  beaks  of  the  superior  forceps  by  presenting  a  second  curva- 
ture, which  allows  the  points  to  come  close  together,  while 
considerable  space  is  left  between  the  long  axis  of  the  beaks, 
permitting  them  to  be  passed  over  the  crowns  of  the  lower  bicus- 
pids and  allowing  the  ends  of  the  beaks  to  be  closely  adjusted 
to  the  constricted  necks  of  these  teeth.  When  circumstances 
require  it,  the  sharpened  edges  will  facilitate  the  severing  of 
portions  of  the  alveolar  process. 

Fig.  8  shows  the  forceps  designed  for  inferior  molars,  known 
as  Standard  forceps  No.  7.  They  are  used  for  the  first  and 
second  molars,  and  to  remove  the  third  molar  after  it  has  been 


FORCEPS  FOR  INFERIOR   TEETH 


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INSTRUMENTS 


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FORCEPS  FOR  INFERIOR  TEETH 


19 


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20 


INSTRUMENTS 


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FORCEPS  FOR  INFERIOR  TEETH  21 

loosened  by  the  application  of  an  elevator,  or  when  the  elevator 
is  not  indicated  for  its  extraction.  The  beaks  are  set  at  an 
obtuse  angle  to  the  handles  and  are  curved  downward,  so  that 
when  they  are  applied  there  is  a  clear  view  of  the  field  of 
operation  and  clearance  of  the  superior  teeth.  They  are  broad 
and  convex  on  the  outer  surface,  while  their  inner  surface  has 
a  double  concavity,  terminating  in  a  point  or  lip,  thereby  pre- 
senting a  form  which  is  a  good  counterpart  of  the  buccal  and 
lingual  sides  of  the  neck  of  an  inferior  molar.  In  applying  them, 
the  points  of  the  beaks  pass  readily  between  the  two  roots  of 
these  teeth.  The  handles  of  these  forceps  are  curved  to  the  left 
of  their  main  axis,  which  enables  the  operator  to  readily  reach 
all  parts  of  the  inferior  arch  while  standing  back  and  slightly 
to  the  right  of  the  patient  and  leaning  over  his  head. 

Figs.  9  and  10  show  supplementary  forceps  also  designed  for 
inferior  anterior  teeth,  known  respectively  as  Standard  forceps 
No.  8  and  No.  9,  and  usually  designated  as  hawksbill  forceps  on 
account  of  the  peculiar  shape  of  their  beaks,  which  somewhat 
resemble  the  bill  of  a  hawk.  These  forceps  are  used  where  any 
of  the  ten  anterior  teeth  are  irregular,  or  where  the  conditions 
are  such  that  it  is  difficult  or  impossible  to  apply  Standard  for- 
ceps No.  6.  The  beaks  are  set  at  an  angle  to  the  axis  of  the 
handles,  and  are  curved  downward,  the  point  of  the  upper  beak 
extending  slightly  over  the  lower  one,  giving  the  beaks  the 
characteristic  hawksbill  shape.  The  No.  9  forceps  are  a  dupli- 
cate of  No.  8,  except  the  beaks  are  much  narrower,  thereby 
permitting  them  to  be  passed  into  spaces  where  the  other  forceps 
cannot  be  applied.  As  the  inferior  incisors  are  frequently  in 
malocclusion,  often  making  it  difficult  to  apply  Standard  forceps 
No.  6  to  them,  no  set  of  instruments  for  extraction  is  complete 
without  these  peculiarly  shaped  forceps,  with  beaks  that  pass 
easily  into  the  narrow  spaces  often  found  in  such  cases. 

The  forceps  described,  and  shown  in  Figs.  1  to  10,  will  suffice 
for  the  majority  of  cases  in  which  forceps  are  indicated.  They 
should  be  carefully  examined  from  time  to  time,  and  given  such 
attention  as  may  be  required.  When  the  beaks  become  dull, 
they  should  ])e  resharponed;  and  when  the  joints  become  loose, 
they  should  l)e  tightened.  If  considerable  o])erating  is  done 
with  them,  they  will  show  the  vrear  of  service,  but  an  occasional 
"toning  up"  will  restore  their  usefulness. 


22 


INSTRUMENTS 


The  selection  of  a  set  of  forceps  is  usually  made  at  the  begin- 
ning of  the  operator's  career  as  an  exodontist — at  a  time  when 
practical  experience  has  not  demonstrated  to  him  the  value  of 
the  proper  selection  of  forceps  necessary  to  meet  his  demands. 
In  such  cases  it  is  recommended  that  a  set  be  selected  as  a  unit, 
and  to  this  set  such  forceps  be  added,  in  the  course  of  his  prac- 
tice, as  may  be  required.  The  set  of  Standard  forceps  described, 
and  taken  as  a  basis  of  illustration  and  description,  has  proved 
most  satisfactory  in  the  hands  of  the  author.  Some  operators 
have,  however,  successfully  used  other  makes  of  forceps,  and 
for  the  information  of  those  who  prefer  a  different  make  the 
following  comparative  list  of  forceps,  with  the  names  of  the 
manufacturers,  is  given: 


standard. 


No.  1 — for  superior  incisors  and  cuspids.  . 

No.  2 — for  superior  bicuspids,  third  mo- 
lars, and  molar  roots 

No.  3  R — for  superior  right  first  and  sec- 
ond molars 

No.  3  L — for  superior  left  first  and  second 
molars 

No.  4 — for  superior  third  molars 

No.  5 — for  superior  roots 

No.  6 — for  inferior  incisors,  cuspids,  bicus- 
pids, and  molar  roots 

No.  7 — for  inferior  molars 

No.  8 — hawksbill,  with  broad  beaks,  for 
inferior  anterior  teeth 

No.  9 — hawksbill,  with  narrow  beaks,  for 
inferior  anterior  teeth 


Claudius  Ash, 
Sons  &  Co. 

No. 

1 

No. 

52 

No. 

17 

No. 
No. 
No. 

18 
19 

76  N 

No. 

No. 

48 
21 

No. 

105 

No. 

106 

S.   S.  White 

Dental 

Mfg.  Co. 


No.  201 

No.    35 

No.  253  R 

No.  253  L 
No.  110 
No.    76  A 

No.  103 
No.  215 

No.  209 


Consolidated 

Dental 

Mfg.  Co. 

Allen  set. 


No.  7 

No.  8 

No.  IR 

No.  IL 
No.  2 
No.  9 

No.  4 
No.  3 

No.  5 

No.  6 


Special  Forceps. — Figs.  11  and  12  show  the  forceps  designed 
for  the  ten  superior  anterior  teeth  when  out  of  alignment  with 
the  arch  and  the  approximating  space  is  narrowed,  known  re- 
spectively as  Standard  special  A  forceps  and  Standard  special  B 
forceps.  These  forceps  are  modifications  of  Standard  forceps 
No.  2,  and  do  not  differ  materially  from  the  latter,  except  in  the 
beaks,  one  beak  being  much  narrower  than  its  opposing  one. 
They  are  made  in  pairs,  affording  the  means  of  a  ready  applica- 
tion to  a  tooth  that  may  be  out  of  alignment,  on  either  side  of 
the  arch,  where  the  adjacent  teeth  closely  approximate  each 
other.  The  cases  requiring  these  instruments  are  not  numerous, 
but  when  a  case  of  this  character  is  presented  they  are  very 


I 


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SPECIAL  FORCEPS 


25 


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26 


INSTRUMENTS 


Fig.  14. — Holding-  the  Forceps.  Illustration  .shows  the  manner  of  properly  holding  the 
straight-handle  forceps  (in  this  case  Standard  forceps  No.  2,  shown  in  Fig.  2)  in 
the  right  hand. 


HOLDING  THE  FORCEPS  27 

serviceable,  as  their  use  may  prevent  disagreeable  fractures  of 
tlie  tooth  to  be  extracted  or  of  the  adjacent  teeth,  which  so 
frequently  occur  by  the  use  of  the  forceps  not  adapted  to  this 
condition. 

Fig.  13  shows  the  author's  improved  lower  molar  forceps,  de- 
signed as  an  improvement  on  Standard  forceps  No.  7  (Fig.  8), 
and  this  modification  is  made  l)y  cutting  about  one  inch  off  the 
long  handle  of  Standard  forceps  No.  7  and  forging  to  the  short- 
ened handle  a  lug,  as  shown  in  Fig.  13,  by  which  a  broad,  heavy 
oval  end  is  obtained.  In  the  application  of  Standard  forceps 
No.  7  there  are  three  essential  movements — (1)  the  forceps  are 
applied  to  the  neck  of  the  tooth,  and  the  hand  is  shifted  back  so 
as  to  bring  the  end  of  the  long  handle  into  the  palm  of  the  hand; 
(2)  pressure  is  now  applied  to  send  the  forceps  down  upon  the 
neck  of  the  tooth;  (3)  the  hand  is  again  shifted  back  to  the 
original  position,  the  tooth  tirmly  gripped,  and  the,  extraction 
movements  begun.  With  these  forceps  as  improved  by  the 
author  this  sequence  of  movements  is  unnecessary.  The  en- 
larged end  of  the  handle  fits  snugly  into  the  palm  of  the  hand, 
and  thus  allows  pressure  to  be  readily  applied  during  any  time 
that  the  tooth  is  being  grasped.  As  the  hand  remains  in  one 
position  on  the  handle  during  the  entire  operation,  the  possi- 
bility of  the  forceps  slipping  off  their  adjustment,  and  producing 
possible  laceration  or  contusion,  is  greatly  lessened.  The  im- 
provement of  these  forceps  serves  still  another  purpose  in  that, 
the  handle  being  of  greater  thickness  than  those  of  Standard 
forceps  No.  7,  the  liand  remains  more  open,  thereby  affording 
the  means  of  a  better  grip  and  steadier  pressure  during  the 
operation. 

The  selection  of  the  force])s  comprising  Figs.  1  to  13  has 
proved  adequate,  in  the  hands  of  the  author,  for  all  cases  in 
which  forceps  are  indicated,  but  any  one  desiring  a  greater  num- 
])er  can  be  accommodated  by  applying  to  the  manufacturers  of 
forceps,  who  have  these  instruments  in  different  shapes  and 
sizes. 

Holding  the  Forceps. — Having  selected  the  pro])er  forceps  for 
the  tooth  to  be  extracted,  the  instrument  is  taken  in  the  right 
hand,  directing  the  lieaks  upward  for  the  superior  teeth  and 
downward  for  the  inferior  teeth.  One  handle  is  placed  toward 
the  palm  of  the  hand,  and  the  opposiug  handle  is  engaged  with 


28  INSTRUMENTS 

the  fingers.  The  thumb  is  placed  on  tlie  inner  surface  of  the 
handle  that  is  away  from  the  palm  of  the  hand,  and  is  used  in 
opening  and  closing  the  forceps.  The  handles  are  then  opened 
sufficiently  for  the  beaks  to  pass  over  the  tooth  that  is  to  be 
removed,  and  the  forceps  are  directed  toward  it.  Care  must  be 
taken,  during  the  introduction  of  the  forceps  into  the  mouth, 
not  to  impinge  on  any  of  the  soft  tissues,  and  to  keep  the  beaks 
as  nearly  as  possible  in  line  with  the  axis  of  the  tooth  to  be 
extracted.  As  soon  as  the  beaks  reach  the  tooth,  they  are 
directed  over  the  crown  and  are  closed  upon  its  neck.  The 
thumb  is  then  withdrawn  from  between  the  handles  and  ])laced 
on  the  outside,  the  handles  being  gripped  at  the  same  time  so 
as  to  close  the  beaks  sufficiently  to  hold  the  forceps  in  place. 
The  hand  is  now  shifted  backward  so  as  to  bring  the  swell-end 
of  the  handle  into  the  palm  of  the  hand  (Fig.  14),  when  pressure 
is  applied  and  the  beaks  are  sent  to  the  marginal  ridge  of  the 
alveolar  process. 

If  the  tooth  is  extensively  decayed  and  the  marginal  ridge  of 
the  alveolar  process  affected  by  caries,  the  beaks  may  be  sent  to 
a  point  beyond  its  edge,  thereby  affording  a  firmer  grasp  of  the 
root.  Too  much  ])ressure  should  not  be  a]iplied,  but  only  suffi- 
cient to  obtain  a  secure  hold,  as  there  is  always  danger  of  crush- 
ing the  tooth.  As  soon  as  this  hold  has  been  obtained,  the  proper 
extraction  movements  are  begun.  After  the  tooth  has  been  loos- 
ened and  is  ready  for  its  exit  from  the  socket,  the  operator  should 
be  careful  not  to  injure  the  lips  or  other  teeth  with  the  forceps  in 
the  tractile  movement.  The  forceps  should  be  continually  under 
the  most  perfect  control,  and  should  never  be  misguided  or  per- 
mitted to  slip  from  the  adjustment.  After  the  forceps  have  been 
applied  to  the  tooth,  it  should  be  carefully  observed  by  the  opera- 
tor throughout  the  extraction  movements. 

ELEVATORS. 

The  elevator  is  an  instrument  designed  ^u'imarily  for  loosening 
a  tooth  or  root  from  its  attachment  ]U'eliniinary  to  its  final  re- 
moval with  the  forceps  or  tweezers.  It  acts  on  the  principle  of  a 
lever,  wedge,  or  inclined  plane,  taking  either  a  contiguous  tooth, 
the  alveolar  process,  or  the  operator's  thumb  or  finger  as  the  ful- 
crum or  supporting  abutment,  and  the  tooth  or  root  to  be  dis- 
lodged as  the  weight.     Its  use  is  indicated  with  a  tooth  or  root  to 


ELEVATORS  29 

wliicli  forceps  cannot  l)e  readily  applied,  as  in  the  case  of  a  frac- 
tured, extensively  decayed,  inaccessible,  wedged,  or  impacted 
tooth.  It  is  also  a  valual)k'  instrument  in  the  extraction  of  a 
tootli  that  is  so  situated  in  relation  to  the  other  teeth  or  parts  of 
the  mouth  that,  when  the  forceps  are  applied,  force  cannot  be 
brought  to  bear  in  a  direction  that  will  effect  its  release.  In  fact, 
the  elevator  should  be  given  preference  to  the  forceps  in  most 
cases  of  badly  broken-down  teeth,  as  its  use  under  such  condi- 
tions will  often  prevent  excessive  laceration.  It  is  often  surpris- 
ing what  excellent  results  can  be  obtained  with  the  elevator  when 
properly  used,  and,  its  appearance  being  entirely  different  from 
the  forceps,  a  patient  who  is  not  under  a  general  anesthetic  will 
submit  to  a  free  application  of  it  with  much  less  apprehension 
than  to  the  use  of  the  forceps.  Adjunctively  and  in  advance  of 
the  forceps,  its  use  is  at  times  indispensable,  particularly  with  the 
inferior  third  molar,  the  loosening  of  the  tooth  in  the  manner  in- 
dicated often  preventing  a  fracture  and  greatly  simplifying  the 
operation. 

The  shank  and  blade  of  an  elevator  should  be  constructed  in 
one  piece,  which  should  be  of  the  best  steel,  and  properly  formed 
to  accord  with  the  location  of  the  teeth  for  which  it  is  designed, 
the  point  or  edge  of  the  blade  being  kept  sharp  when  designed  for 
cutting.  The  metal  handle,  which  is  a  continuation  of  the  shank, 
should  be  shaped  to  fit  comfortably  into  the  palm  of  the  hand  to 
allow  a  firm  grasp. 

The  elevators  described  have  been  found  most  effective  in 
usage,  and  are  so  simple  in  their  construction  that  by  a  little 
practice  their  proper  manipulation  is  readily  acquired.  The  be- 
ginner should  avoid  haste  in  operating  with  this  form  of  instru- 
ment. He  should  adjust  the  blade  with  precision,  and  apply  the 
power  gently,  but  firmly,  maintaining  perfect  control  of  every 
movement,  for,  should  the  blade  slip  from  the  position  in  which  it 
is  engaged,  considerable  laceration  of  tissue  may  ensue. 

Straight-Shank  Elevator. — The  simplest  form  of  elevator  is 
shown  in  Fig,  15.  The  shank  is  straight  and  in  direct  line  with 
the  axis  of  the  handle.  The  blade  is  a  continuation  of  the  shank, 
being  bent  only  slightly  out  of  its  line,  and  is  about  three- 
sixteenths  of  an  inch  in  width,  convex  on  one  side  and  concave 
on  the  opposite;  it  tapers  down  to  a  thin,  oval  point,  which  gives 
it  a  wedge-like  form,  being  suitably  shaped  for  adaptation  to  the 


30 


INSTRUMENTS 


convex  surface  of  tlie  neck  of  a  tooth.  It  is  nsed  where  direct 
access  is  obtainable  and  where  little  cutting  of  process  is  re- 
quired; and  for  teeth  not  too  tirmly  attached,  as  badly  broken- 
down  roots  or  deciduous  teeth, 
this  elevator  is  a  valuable  in- 
strument. It  is  held  by  plac- 
ing the  handle  well  into  the 
palm  of  the  hand,  the  index 
finger  and  thumb  resting  on 
the  shank  to  guide  the  instru- 
ment, while  the  remaining 
fingers  firmly  grip  the  handle. 
In  use  it  should  be  adjusted  to 
the  more  accessible  and,  if 
possible,  stronger  part  of  the 
tooth,  and  sufficient  force  of 
a  pushing  nature,  combined 
with  a  lever-like  action,  ap- 
l^lied  to  lift  the  tooth  from  the 
socket. 

Curved-Shank  Elevator. — 
This  elevator  (Fig.  16)  is  a 
modification  of  the  primary 
form  of  elevator,  so  as  to  per- 
mit its  use  in  a  case  where  the 
parts  are  inaccessible  to  direct 
application.  The  shank  is  bent 
out  of  a  direct  line  by  a  double 
angular  curve,  and  terminates 
in  a  blade  that  is  set  at  an 
obtuse  angle  to  the  long  axis 
of  the  instrument.  It  is  made 
in  pairs,  which,  combined  with 
its  double  curvature,  renders 
either  one  or  the  other  instru- 
ment applicable  to  all  parts  of 
the   inferior   arch.     The  point 

Fig.     15.-Straight-Shank    Elevator.      For  ^^       COUCaVcd,       and,       rOUUdiug 

extracting     superior     anterior     roots.  /Inwn    in    n    fliin     Arlo-P     -fArinc    n 

Used    also    for    superior    and    inferior  uOVVIl    LO    d    inill    euge,    iOimS    d 

deciduous  teeth  and  posterior  inferior  „,„^,1    „^     „.4-„^„„„i    x       j.i  i     ^ 

roots  not  firmly  attached.  good  Counterpart  to  the  alveo- 


ELEVATORS 


31 


lar  process   surrounding   the  inferior   teeth.     This   elevator   is 
used   for   inferior   incisor,    cuspid,   bicuspid,   and   molar   roots. 
Application  can  he  made  to  the  lingual  or  lal)ial  surface  of  a 
tooth,  although  the  lal)ial  sur- 
face is  usually  the  more  favor- 
able. 

Labial  Application. — In  ap- 
plying the  curved-shank  eleva- 
tor to  the  labial  side  of  a  root, 
the  blade  is  forced  as  far  down 
as  possible  under  the  free  mar- 
gin of  the  gum  with  a  steady 
downward  pressure.  After  ad- 
justment is  secured,  pressure 
is  applied  lingually  in  con- 
junction with  an  upward  move- 
ment, dislodging  the  tooth  from 
its  socket.  If,  during  the  ef- 
fort to  dislodge  the  tooth,  re- 
sistance is  encountered,  the 
blade  is  forced  further  down 
on  the  root  each  time  pressure 
is  exerted,  the  sharp  edge  of 
the  instrument  cutting  into, 
when  necessary,  a  portion  of 
the  process  to  loosen  the  tooth. 

Lingual  Application .  — When 
making  a  lingual  application, 
the  blade  of  the  elevator  may 
be  set  somewhat  lower  on  the 
tooth  than  in  the  case  of  a 
labial  application,  as  the 
process  on  the  lingual  side 
yields  more  readily.  Less  force 
is  applied,  and  the  extraction 
movement,  while  slightly  labial, 
should  be  directed  principally 
upward.    Care  should  be  taken 

to     maintain     a     secure     adjust-       pjg       le -Curved-Shank      Elevator.      For 

ment  of  the  elevator.  Srs.''"'"^  "'"'"''  '"'"     ^''''  " 


32 


INSTRUMENTS 


Knott  Elevator. — This  elevator  (Fig.  17),  designed  by  Dr.  F. 
W.  Knott,  is  made  in  pairs,  Nos.  1  and  2,  for  mesial  and  distal 
application.     The   shank   is   abont   two   inches   long,   and  bent 


No.    1. 


No.  2. 


Fig-.   17. — Knott  Elevator.     For  extracting-  inferior  molar  roots.     Made  in  pairs,   Nos.  1 
and  2,  for  mesial  and  distal  application. 

slightly  upward  the  last  half  inch  of  its  length,  so  as  to  allow  the 
])oint  to  be  inserted  in  line  with  the  long  axis  of  the  root,  while 
the  shank  remains  well  above  the  gum  margin,  which  permits  a 


ELEVATORS  33 

tirm  downwaixl  pressure.  The  blade  is  triangular  in  shape, 
three-eighths  of  an  inch  long,  slightly  curved,  with  the  outer  edges 
beveled,  and  terminates  in  a  sharjj  point.  It  is  used  mainly  for 
the  extraction  of  the  posterior  inferior  teeth  where  there  is  an 
adjacent  tooth  or  heavy  process  to  serve  as  the  fulcrum.  When 
applied,  it  is  held  firmly  in  the  right  hand,  and  the  point  is  passed 
between  the  root  to  be  extracted  and  the  contiguous  tooth  and 
alveolar  process,  with  the  broad  surface  of  the  blade  toward  the 
root,  pressure  being  applied  in  a  downward  direction.  When 
thus  forced  between  two  bodies,  it  acts  as  a  wedge,  and  separates 
them  from  each  other.  The  top  of  the  handle  is  turned  toward 
the  fulcrum  sufficiently  to  cause  the  point  to  take  a  firm  hold  on 
the  root,  after  which  a  further  turn  of  the  handle  will  raise  the 
root  from  the  socket. 

The  author  has  found  that  the  Knott  elevator  possesses  many 
good  features,  and,  by  slight  modification,  has  greatly  increased 
its  usefulness,  A  regulation  pair,  reduced  about  one-third  of  the 
original  size,  are  well  adapted  to  the  extraction  of  fine,  delicate 
roots  that  are  either  deep-seated  or  wedged  betw^een  adjacent 
teeth,  especially  when  the  intervening  space  is  so  narrow  that 
only  a  small  instrument,  such  as  this  elevator,  can  be  applied  for 
their  removal.  They  should  be  made  with  all-metal  handles 
instead  of  wooden  handles  fastened  to  metal  shanks,  as  usually 
manufactured,  for,  if  made  of  one  piece  of  metal,  they  can  be 
sterilized  by  heat  without  loosening  the  handles. 

Author's  Lower  Root  Elevator. — This  elevator  (Fig.  18)  was 
designed  by  the  author  for  the  extraction  of  inferior  molar  roots, 
and  is  made  in  pairs,  Nos,  1  and  2,  for  mesial  and  distal  applica- 
tion. In  practice  it  has  i)roven  to  be  a  most  efficient  instrument, 
and  its  use  is  indicated  where  the  roots  are  partially  united  or 
entirely  separated,  and  w^here  they  are  covered  l)y  soft  tissue  or 
deeply  seated.  In  most  of  these  conditions  it  is  superior  to  any 
other  instrument,  and  it  is  invaluable  as  the  primary  instrument 
in  the  removal  of  an  inferior  third  molar  that  is  displaced  too  far 
buccally  for  the  second  molar  to  be  used  as  a  fulcrum,  or  where 
the  third  molar  is  isolated,  whether  the  crown  is  intact  or  has 
been  destroyed  by  caries,  A  secure  adjustment  and  firm  leverage 
can  be  obtained  with  the  elevator.  The  blade  is  of  a  size  that 
will  bear  a  great  amount  of  severe  usage,  but  is  not  too  large 
to  interfere  with  its  free  application.     The  edges  of  the  blade  are 


34 


INSTRUMENTS 


No.  1. 


<l^^i 


No.  2. 


Fig.  18. — Author's  Lower  Root  Elevator.  For  extracting-  inferior  molar  roots  when 
partially  united  or  entirely  separated.  Used  also  for  the  removal  of  isolated  and 
displaced  inferior  third  molars.  Made  in  pairs,  Nos.  1  and  2,  for  mesial  and  distal 
application. 


ELEVATORS  35 

sufficiently  sharp  to  cut  through  the  alveolar  process  when  neces- 
sary, and  the  point  is  so  shaped  that  it  can  readily  engage  the 
root  of  a  tooth.  The  handle  is  of  such  form  that  it  may  be 
securely  held  in  the  hand,  as  shown  in  Fig.  19,  and,  if  during  the 
execution  of  any  extraction  movement  with  this  elevator  heavy 
resistance  is  encountered,  the  instrument  can  be  kept  in  perfect 
control.  In  addition  to  this  pair,  it  is  advisable  to  have  a  pair 
with  the  shank  about  one  and  one-half  inches  longer  (Fig.  20), 
Nos.  3  and  4,  to  enable  the  operator  to  work  on  the  left  arch  from 
the  right  side  of  the  patient  whenever  possible. 


Fig.  19. — Holding  the  Elevator.  Illustration  shows  the  manner  of  properly  holding  an 
elevator  (in  this  case  the  author's  lower  root  elevator  No.  2,  shown  in  Fig.  18)  for 
making  an  application. 


Lecluse  Elevator.— This  elevator  (Fig.  21)  is  used  mainly  in 
the  extraction  of  the  inferior  third  molar,  and  for  this  purpose  it 
is  far  superior  to  the  Physick  forceps,  which  are  so  commonly 
used  in  such  case.  It  can  be  used  also  for  the  inferior  second 
molar  when  the  third  molar  is  missing.  While  both  the  Physick 
forceps  and  Lecluse  elevator  were  designed  for  the  same  purpose, 
the  methods  of  their  use  are  very  dissimilar.  Force  is  more 
effectively  transmitted  with  the  elevator,  with  less  stress  on  the 
fulcrum,  than  with  the  forceps,  especially  where  the  tooth  to  be 
removed  is  impacted.  In  the  transmission  of  force  the  forceps 
act  first  as  a  double  wedge  aud  then  as  a  lever,  working  over  the 
contact  point  of  the  approximating  tooth,  which  in  such  case  be- 
comes the  fulcrum.  This  application  subjects  the  tooth  that  is 
being  used  as  a  fulcrum  to  severe  strain  at  its  neck,  which  may 


36 


INSTRUMENTS 


No. 


No.   4. 


Fig.  20. — Author's  Special  Elevator.  Same  instrument  as  shown  in  Fig.  18,  except  that 
the  shank  is  one  and  one-half  inches  longer,  so  that  it  may  be  used  for  operating  on 
the  left  side  of  the  arch  from  the  operator's  position  on  the  right  side  of  the  pa- 
tient.    Made  in  pairs,  Nos.  3  and  4,  for  mesial  and  distal  application. 


ELEVATORS 


37 


No.   1. 


Fig.  21. — Lecluse  Elevator.  For  extracting  inferior  tliird  molars.  Used  also  for  the 
second  molar  when  the  third  molar  is  missing.  The  smaller  illustration  gives 
another  view  of  the  angle  in  the  shank.     Regular  length,  No.  1. 


38  INSTRUMENTS 

result  in  a  fracture.  "With  the  elevator  the  force  is  transmitted 
to  the  tooth  to  be  removed  on  the  principle  of  the  inclined  plane, 
using  the  gingival  third  of  the  approximating  tooth  as  the  abut- 
ment, which  greatly  reduces  the  strain  on  this  tooth.  It  is  prob- 
ably a  little  more  difficult  to  master  the  manipulation  of  the  ele- 
vator, but,  once  mastered,  a  better,  safer,  and  surer  operation 
can  be  accomplished  with  it  than  with  the  Physick  forceps.  The 
manner  of  holding  this  instrument  is  shown  in  Fig.  22,  and  the 
technic  of  its  employment  in  the  removal  of  the  inferior  third 
molar  is  described  in  the  text  on  that  subject. 

Two  Lecluse  elevators,  or  what  may  be  termed  a  set,  are  neces- 
sary for  a  proper  equipment — viz.,  one  a  regulation-length  ele- 


Fig.  22. — Holding  tiie  Elevator.  Illustration  show.s  the  manner  of  properly  holding-  an 
elevator  (in  this  case  the  Lecluse  elevator  No.  1,  shown  in  Fig.  21)  for  making 
application. 

vator  as  usually  made,  to  be  used  for  teeth  on  the  right  side  of 
the  arch,  and  the  other  with  the  shank  lengthened  one  and  one- 
half  inches,  as  designed  by  the  author  (Fig.  23,  No.  2),  for  opera- 
tions on  the  left  side  of  the  arch  while  the  operator  is  standing 
on  the  right  side  of  the  patient. 

Cryer  Elevator. — This  elevator  (Fig.  24)  is  similar  to  the 
Knott  elevator,  but  the  blade  is  thinner  and  narrower,  and  tapers 
to  a  tiner  point.  It  is  made  in  pairs,  Nos.  1  and  2.  The  shank 
and  blade  of  the  instrument  are  in  one  piece,  and  the  handle, 
which  is  of  metal,  is  of  a  size  to  afford  a  secure  grip  (Fig.  26). 
This  elevator  is  not  strong  enough  to  be  used  on  the  inferior  first 
molar  roots  when  they  are  large  and  firmly  attached,  but,  when 


ELEVATORS 


39 


Fig.  23.— Author's  Modified  Lecluse  Elevator.  Same  in.strument  as  shown  in  Fig.  -1, 
except  that  the  shank  is  one  and  one-half  inches  longer,  so  that  it  may  be  usea 
for  operating  on  the  inferior  left  third  molar  from  the  operators  position  on  the 
right  side  of  the  patient.     Modified  length,  No.  2. 


40 


INSTRUMENTS 


No. 


No. 


No.   4. 


Fig-.    24. — Cryer   Elevator.     For   extracting 
roots.     Made  in  pairs.  Nos.   1  and  2. 


Fig.  2.5.— Author's  Modified  Cryer  Ele- 
vator. Same  instrument  as  shown  in 
Fig.  24,  except  that  the  shank  is  one 
and  one-half  inches  longer.  Made  in 
pairs,  Nos.  3  and  4. 


SCREW-PORTE 8  AND  REAMER  41 

the  siiiTouncling  tissues  are  partially  broken  down  and  the  roots 
are  loosely  adherent,  good  work  can  l)e  done  w^itli  it  if  properly 
used.  For  superior  molar  roots  and  other  small  roots  it  may 
often  be  used  to  advantage. 

The  author  has  also  increased  the  efficiency  of  this  instrument 
by  designing  a  pair  with  the  shank  one  and  one-half  inches 
longer  than  the  standard  size  (Fig.  25,  Nos.  3  and  4).  This  in- 
strument is  used  to  operate  on  the  roots  of  teeth  in  the  left  side 


Fig.  26.— Holding  the  Elevator.  Illustration  shows  the  manner  of  properly  holding  an 
elevator  (in  this  case  the  Cryer  elevator,  shown  in  Fig-.  24)  for  making  an  appli- 
cation. 

of  the  mouth  without  the  operator  changing  his  position  from 
the  right  side  of  the  patient,  and  for  cases  difficult  of  access  with 
the  shorter  instrument. 

SCREW-PORTES  AND  REAMER. 

Screw-Portes  and  Morrison  Reamer. — The  screw-porte  is  used 
only  for  the  extraction  of  roots.  It  is  especially  serviceable 
where  a  tooth  is  decayed  or  is  fractured  below  the  margin  of  tlie 
alveolar  process,  and  the  soft  tissues  almost  cover  the  root,  mak- 
ing it  difficult  to  apply  the  forceps  or  elevator  to  extract  it  with- 
out severely  injuring  the  surrounding  tissues.  The  location 
most  available  for  the  use  of  the  screw-porte  is  the  region  of  the 
six  superior  anterior  teeth,  as  these  teeth  naturally  have  large 
root  canals,  which  is  favorable  to  the  introduction  of  the  screw. 
Its  employment  in  the  removal  of  the  su])erioi-  (irst  biciisi»id  is 
not  generally  ])racticable  on  account  of  the  l)ifiir('ated  i-oots,  but, 
if  the  roots  are  separated  and  the  canals  large  enough  to  receive 
the  screw,  it  can  be  used.     It  may  be  used  also  for  the  superior 


42 


INSTRUMENTS 


second  bicuspid,  particularly  if  the  patient  has  a  mouth  that  per- 
mits free  access  to  the  tooth.  For  the  superior  molar  roots  it  is 
not  well  adapted,  except  when  the  roots  are  separated  from  each 

other  and  accessible,  in  which  case  good 
work  may  sometimes  be  done  with  it. 

The  canals  of  the  four  inferior  incisors 
are  too  small  for  the  reception  of  the  in- 
strument, and  consequently  it  cannot  be 
employed  successfully  with  these  teeth. 
A  screw-porte  made  fine  enough  to  enter 
these  canals  would  not  have  sufficient 
strength  to  withstand  the  strain  necessary 
for  the  extraction.  The  inferior  cuspids 
and  bicuspids  are  more  favorable  for  its 
use.  The  operator  must,  however,  main- 
tain a  direct  line  with  the  tooth  when  the 
instrument  is  inserted  and  during  the  ex- 
traction, which  in  such  cases  is  acquired 
by  a  position  directly  over  the  head  of  the 
patient.  With  the  inferior  molars  the 
use  of  the  screw-porte  is  prohibited  in 
the  anterior  roots  on  account  of  the  two 
canals.  It  may  sometimes  be  used  in  a 
posterior  root  when  the  sliaj^e  of  the  canal 
and  the  location  of  the  root  is  favorable. 
When  a  tooth  has  been  mutilated  by 
an  attempted  extraction  and  the  pulp  has 
been  removed,  the  screw-porte  will  often 
be  found  to  work  excellently,  but  its  util- 
ity is  uncertain  in  a  case  where  the  roots 
are  extensively  decayed.  If,  however,  the 
decay  is  not  extensive,  the  soft,  decayed 
structure  may  l)e  removed  from  the  root 
canal  with  the  reamer  (Fig.  27)  or  with 
a  bur,  after  which  the  screw-porte  is  in- 
serted into  the  canal  and  given  a  half- 
turn,  the  half-turn  being  repeated  until 
Fig.  27.— Morrison  Reamer,     tlic  instrument  is  fimilv  attached  to  the 

For    removing    soft    de-  »       i-      i  •     ' 

cayed    tootii    structure     root.     A   little   practicc   Will   enable   the 

from    a    root    canal    pre-  ^ 

ceding  tiie  application  of     operator  to  adiust  the  screw-porte  with 

a  screw-porte.  i  o  j. 


SCREW-PORTED  AND  REAMER 


43 


dexterity.  After  a  good  hold  is  secured,  a  firm  grip  is  taken  on 
the  handle,  and  the  root  is  extracted  by  force  exerted  in  a  direct 
line  with  the  axis  of  the  root.  No  luxation  should  be  tried,  as 
such  attempt  is  liable  to  break  the  instrument.  Caution  must 
also  be  exercised  against  splitting  the  root  in  an  effort  to  secure 
too  firm  an  anchorage.     If,  however,  the  root  splits,  the  screw 


Fig.  28.— Long-Shank  Screw-Porte.  The 
handle  is  permanently  attached  to  the 
shank. 


Fig.  29. — Long-Shank  Screw-Porte.  With- 
out handle.  The  shank  has  a  ring  end 
for  receiving  a  small  bar  as  a  handle. 


will  usually  bring  out  one  of  the  segments,  and  perhaps  both. 
The  remaining  part,  if  any,  can  be  loosened  by  inserting  an  ordi- 
nary enamel  chisel  between  the  root  and  the  alveolus,  using  the 
process  as  a  fulcrum,  and  applying  pressure.  When  the  root 
fragment  gives  way,  its  final  removal  may  be  accomplished  with 


Derenberg  tweezers. 


44 


INSTRUMENTS 


Tlie  screw-porte  should  be  uiacle  of  steel,  and  the  threads 
must  be  sharjo  to  insure  a  safe  hold.  If  the  threads  become 
worn,  they  should  be  resharpened  or  the  instrument  discarded. 
The  handle  should  be  made  sufificientlY  strong  so  that  it  will  not 
break  when  the  tractile  movement  is  imparted.  Whenever  con- 
ditions allow  it  to  be  introduced  into  the  root,  the  style  of  instru- 
ment shown  in  Fig.  28  should  be  given  preference.  This  style 
is  made  about  three  and  one-half  inches  long,  with  screw-shaft 
and  handle  united.  The  operator  can  maintain  a  firmer  and 
steadier  grip  with  this  screw-porte  than  with  one  where  a  sepa- 
rate handle  is  improvised,  as  shown  in  Fig  29,  which  has  a  ring 
on  the  end  for  the  reception  of  a  small  instrument  or  bar  to  act 
as  a  handle  for  screwing  it  into  position  and  for  the  extracting 
movement.     Tlie  use  of  the  latter  is  indicated  only  when  the  loca- 


Fig-.  30.— Short-Shank  Screw-Porte.  With- 
out handle.  The  shank  has  a  ring  end 
for  receiving  a  small  bar  as  a  handle. 


Fig.  31. — Keith  Screw-Porte.  Used  where 
a  screw-porte  with  a  shank  cannot  be 
applied. 


tion  of  the  root  will  not  permit  the  fixed  handle  of  the  former  to 
be  turned  in  order  to  introduce  it  into  the  root.  An  instrument 
with  a  shorter  shank  (Fig.  30)  is  used  for  bicuspid  and  molar 
roots,  and  is  manii)ulated  in  the  same  manner  as  the  long  one. 

Keith  Screw-Porte. — Roots  that  are  not  accessible  to  shank 
screw-portes  (Figs.  28,  29,  30)  may  somethnes  be  extracted  with 
a  smaller  instrument  designed  by  Dr.  H.  H.  Keith  (Fig.  31). 
The  screw  and  handle  of  this  instrument  are  constructed  in  one 
piece,  and  there  is  no  intervening  shank.  The  screw  is  inserted 
into  the  root  canal,  and  the  handle  turned  with  the  fingers  until 
the  screw  has  taken  hold,  after  which  the  turning  is  continued 
by  the  a])plication  of  forceps  to  the  handle  until  the  screw  is 
firmly  fastened.  As  the  beaks  of  the  forceps  are  already  on  the 
instrument,  it  is  only  necessary  to  apply  the  tractile  movement 


TWEEZERS— LANCET 


45 


to  complete  tlie  extraetion,  taking  care  to  ex- 
ti-act  ill  line  with  tlie  axis  of  the  root. 


A  practical  lancet  (Pig.  33) 
is     the     all-metal     Vol  land 

g.    32.    —    Derenberg    ,  .    ,  a    ±    i  ii  i- 

Tweezers.    For  re-   lauce,  witli  a  Hat  handle  ot 

moving  loose  process  .  ii   •    i  mi 

and  roots,  dressing  conveiiient    thickness.      llie 

wounds,  and  for  all 

purposes    requiring  ebouY-  or  ivorv-handled  in- 

neavy  tweezers.  •'  •' 


DERENBERG  TWEEZERS. 

These  tweezers  (Fig.  32)  are  made  with  the 
blades  constructed  similar  to  those  of  root  for- 
ceps, but  not  so  heavy  or  so  strong.  They  are 
very  practical  in  removing 
a  part  of  a  tooth  or  root  that 
is  loosely  attached  to  the 
tissue.  The  tweezers  are 
amply  strong  to  detach  such 
roots,  as  well  as  loose  parti- 
cles of  process,  overhanging 
tissue,  and  deciduous  teeth 
that  do  not  offer  much  re- 
sistance. They  are  also  em- 
ployed in  dressing  wounds, 
carrying  cotton  and  gauze, 
removing  blood  clots,  etc. 
In  fact,  the  uses  to  which 
they  are  adapted  are  so 
varied  that  these  tweezers 
are  practically  indispensable 
in  a  well-appointed  office. 
When  they  are  used  to  serve 
the  same  purpose  as  forceps, 
the  mental  effect  on  the  pa- 
tient is  not  so  intimidating, 
which  is  a  specially  valuable 
consideration  with  children 
or  nervous  patients. 

LANCET. 


Fig.  .33. — Lancet.  For 
lancing  soft  tissue 
over  roots  and  over 
impacted  and  around 
isolated  teeth.  Used 
also  for  all  minor 
incisions. 


46  INSTRUMENTS 

strument  cannot  l3e  recommended,  as  it  is  almost  impossible  to 
keep  it  sterilized.  The  lancet  is  used  to  sever  the  soft  tissue 
from  around  teeth  wherever  it  is  adherent  to  them,  to  cut  away 


Fig.  34. — Curved  Scissors.  For  cutting-  away  soft  tissues  around  a  socket  and  over  a 
tooth,  and  for  making  incisions.  Tlie  blades  are  separable,  so  that  the  scissors  can 
be  readily  sterilized. 

superfluous  tissue,  relieve  abscesses,  and  make  all  minor  inci- 
sions. It  should  be  employed  sparingly  preceding  the  operation 
of  extraction,  as  the  consequent  hemorrhage  obscures  the  field 


CURVED  SCISSORS— SYRINGES 


47 


of  operation  and  renders  the  application  of  the  forceps  uncertain. 
Frequently  it  is  used  unnecessarily  with  deciduous  teeth,  as 
these  teeth  are  seldom  firmly 
attached,  and  the  lancing  of 
the  gum  has  a  tendency  to 
frighten  the  little  patient,  often 
making  a  difficult  task  out  of 
an  otherwise  simple  operation. 


CURVED  SCISSORS. 

Curved  scissors  (Fig.  34)  are 
often  needed,  and  are  used  for 
severing  gum  tissue  from  loose 
teeth  or  roots,  and  for  clipping 
the  tissue  from  around  the 
socket  after  extraction.  When 
access  can  be  had,  more  accu- 
rate incisions  over  impacted 
teeth  can  be  made  with  them 
than  with  the  lancet.  To  per- 
mit easy  sterilization,  the  scis- 
sors with  a  separable  joint  are 
preferred. 

SYRINGES. 

Standard  Syringe. — In  Fig. 
35  is  shown  a  standard  form  of 
syringe  used  for  clearing  debris 
from  around  the  tooth  prior  to 
operating  and  for  treating  a 
socket  after  extraction.  Con- 
siderable force  can  be  obtained 
with  it — sufficient  to  wash  any 
loose  particles  of  tooth  struc- 
ture or  alveolar  process  from  a 
socket — and  it  is  almost  indis- 
pensable for  irrigating  abscess 
pockets.  Though  not  always 
to  be   had,   a   compressed   air 


Fig.  35.— Standard  Syringe.  For  irrigating 
and  cleansing  oral  surfaces  and 
lesions.     Made  of  metal. 


48 


INSTRUMENTS 


outfit,  with  a  full  complement  of  spray  liottles,  may  be  used 

instead  of  this  standard  form  of  syringe. 

Bismuth  Syringe. — In  Fii>'. 
36  is  shown  a  syringe  of  com- 
paratively recent  origin,  which 
is  used  for  carrying  bismuth 
paste  into  tooth  sockets  and 
sinuses  when  such  procedure  is 
indicated.  It  has  a  metal  bar- 
rel, fitted  with  a  metal  plunger, 
and  its  breech  is  readily  un- 
screwed, allowing  the  removal 
of  the  piston  for  the  purpose  of 
filling  the  instrument.  It  is 
fitted  with  a  broad  finger-piece, 
which,  in  conjunction  with  the 
large  butt  on  the  end  of  the 
])iston-rod,  permits  the  applica- 
tion of  such  pressure  as  may  be 
necessary  to  force  the  semi- 
solid contents  of  the  syringe 
into  any  desired  area.  As  sup- 
1)1  ied  by  the  manufacturer,  the 
instrument  is  furnished  with 
two  needles — one  is  a  long- 
shank  hypodermic  needle  and 
the  other  a  larger  needle  with 
blunt  point.  The  fine  needle 
is  not  so  practical,  however,  as 
the  larger  one  for  use  in  con- 
nection with  the  treatment 
after  the  extraction  of  a  tooth. 
Wlien  introducing  the  paste, 
the  blunt  point  of  the  needle 
should  reach  the  apex  of  the 
socket  and  is  gradually  with- 
drawn as  the  socket  becomes 
filled.    A  layer  of  gauze  placed 

Fig.   36.-Bismuth   Syringe.     For   carrying       ^^Cr    the   filled    SOckct   will    prO- 
bismu.h    paste    into    a    socket    or    a       ^.^^^^   ^^m  CSCape  of  the  pastc. 


CURET— MOUTH-GAG 


49 


CURET. 

The  cnret  is  an  essentia  I  instrument  for  the  exodontist.  The 
one  shown  in  Fig.  37  is  a  double-ended  spoon  curet,  which  is  a 
very  practical  form  of  this  instrument  for  use 
in  the  mouth.  The  shape  is  such  that  all  of 
the  alveoli  may  be  reached  with  it,  and,  being 
double-ended,  affords  a  means  of  a  quick 
change  of  instruments,  which  is  an  important 
feature,  because  it  is  frequently  necessary  to 
curet  several  sockets  at  one  sitting.  Dex- 
terity in  the  use  of  the  curet  should  be  cul- 
tivated, as  in  many  cases  of  inflammatory 
conditions  about  a  tooth  nothing  else  will 
afford  the  same  degree  of  relief  after  its 
extraction  as  a  careful  curetting  of  the 
socket,  further  relieving  the  congested  condi- 
tion, causing  a  more  liberal  evacuation  of 
pus,  or  insuring  the  removal  of  gangrenous 
or  necrotic  tissue. 

MOUTH-GAG. 


The  mouth-gag  shown  in  Fig.  38  was  de- 
signed by  Dr.  A.  Brom  Allen,  but  the  blades 
have  been  slightly  modified  by  the  author.  It 
is  intended  to  take  the  place  of  the  Mason  or 
the  Doyen-Jansen  gag  for  opening  the  mouth. 
In  a  case  where  there  is  a  tension  of  the  mus- 
cles, caused  by  inflammatory  conditions,  the 
use  of  the  mouth-gag  may  be  necessary,  as 
access  to  the  field  of  operation  in  such  cases 
can  be  gained  only  by  forcibly  opening  the 
mouth.  When  a  general  anesthetic  is  admin- 
istered, especially  nitrous  oxid  and  oxygen, 
the  prop  is  sometimes  displaced,  particularly 
with  children,  when  it  may  also  be  necessary 
to  open  the  mouth  with  a  gag. 

The  long  handles  of  the  Allen  gag  present 
an  advantage  over  the  Mason  or  the  Doyen- 


Fig.  37.  —  Curet.  For 
curetting  a  socket 
after   extraction. 


50 


INSTRUMENTS 


Fig-.  38.— Allen  Mouth-Gag.  Two-thirds  actual  size.  For  opening  the  mouth  wheie 
there  is  a  tension  on  the  muscles,  and  for  holding  the  mouth  open  where  the 
mouth-prop  has  been  displaced  during  the  administration  of  a  general  anestnetic. 


WOODEN  WEDGE 


51 


Jansen  gag,  as  with  them  the  instrument  can  be  held  more 
steadily,  thereby  increasing  the  ease  of  the  manipulation  and 
reducing  to  a  minimum  the  danger  of  slipping,  and  also  atford- 
ing  greater  leverage.  The  blades  are  strong,  and  taper  to  quite 
a  thin,  but  dull,  edge.  The  instrument 
should  be  applied  by  the  operator's  as- 
sistant, who  inserts  the  blades  between 
the  teeth,  and,  by  closing  the  handles, 
opens  the  mouth  to  any  desired  extent, 
holding  it  in  that  position  until  the  com- 
pletion of  the  operation.  The  length  of 
the  handles  also  prevents  the  hands  of 
the  assistant  from  getting  in  the  way  of 
the  operator  and  interfering  with  his 
work. 

The  gag  is  always  applied  to  the  side 
opposite  the  field  of  operation.  It  is 
better  to  have  the  blades  covered,  which 
can  be  done  by  slipping  a  piece  of  steril- 
ized rubber  tubing  over  them.  This  cov- 
ering will  keep  the  metal  from  coming- 
in  contact  with  and  possibly  injuring 
the  enamel  of  the  teeth. 


WOODEN  WEDGE. 

Where  the  teeth  are  closed,  so  that  it 
is  impossible  to  insert  the  blades  of  the 
mouth-gag  between  them,  the  prelimi- 
nary use  of  the  wooden  wedge  is  indis- 
pensable. The  wedge  (Fig.  39)  is  made 
of  a  piece  of  soft  wood,  and  is  of  the 
size  and  shape  shown.  It  is  inserted 
between  the  molar  teeth,  if  present,  be- 
cause this  is  the  most  favoraljle  place 
for  its  application.  The  flat  surface  of 
the  wedge  is  placed  between  the  teeth, 
when  with  a  firm  grip  it  is  turned  on  its 
edge  until  sufficient  space  is  secured  for 
the  insertion  of  the  Allen  gag.  The 
operator  should  make  the  application  of 


Fig.  39. — ^Wooden  Wedge.  For 
opening-  the  mouth  pre- 
liminary to  the  use  of  the 
mouth-gag.  Used  also  to 
open  the  mouth  independ- 
ently of  the  employment  of 
the  mouth-gag. 


52 


INSTRUMENTS 


tlie  wedge,  and,  when  the  mouth  is  open  sufficiently,  the  assistant 
should  insert  the  gag  and  continue  the  opening  process  until 
access  is  obtained,  when  the  operator,  discarding  the  wedge, 
proceeds  with  the  extraction.  If,  however,  space  will  permit,  a 
small  piece  of  wood,  with  a  string  attached,  is  placed  between 
the  teeth  before  the  patient  is  anesthetized.     The  small  opening 


Fig.  40. 


-Retractor.     For  retracting  the  gum  tissue  over  the  socket  and  for  holding  the 
incised  soft  tissue  apart  when  operating  on  an  impacted  tooth. 


thus  afforded  will  allow  the  freer  introduction  of  the  wedge.  If 
the  muscular  tension  is  not  too  great  and  the  molar  teeth  are  in 
place,  and  the  field  of  operation  is  on  the  right  side,  the  wooden 
wedge,  applied  by  the  assistant  on  the  left  side,  will  frequently 
be  all  that  is  required  for  opening  the  mouth.  Care  should  be 
taken,  when  using  the  wedge,  not  to  allow  it  to  impinge  on 
the  lips. 


RETRACTOR— CHISEL 


53 


RETRACTOR. 

The  retractor  (Fig-.  40)  is  a  small 
dilating  instrument  made  of  spring  wire 
and  having  the  action  of  a  spring  hinge. 
Each  end  of  the  retractor  terminates  in 
a  fine  point,  which  extends  outward  and 
at  right  angles  to  the  axis  of  the  instru- 
ment. It  is  employed  for  keeping  open 
the  field  of  operation  after  an  incision 
has  been  made  in  the  soft  tissues  x)relim- 
inary  to  operating  on  the  deeper  struc- 
tures. As  soon  as  an  incision  is  made 
to  expose  the  process  or  tooth  to  be  re- 
moved, the  two  points  of  the  retractor 
are  placed  in  the  respective  sides  of  the 
cut,  and  the  constant  outward  spring 
force  of  the  two  ends  of  the  instrument 
keeps  the  walls  dilated.  It  is  also  used 
to  retract  the  soft  tissues  about  the 
sockets  where  they  close  the  orifice  and 
the  condition  of  the  alveolus  necessitates 
curetting  and  irrigating.  The  retractor 
is  held  in  place  Ijy  the  assistant,  or  by 
the  operator  if  it  is  convenient  for  him 
to  devote  his  left  hand  to  this  purpose. 


CHISEL. 

The  instrument  shown  in  Fig.  41  is 
known  as  a  mastoid  chisel.  It  is  used 
for  separating  the  roots  of  badly  de- 
cayed inferior  molars,  which  operation 
is  performed  by  adjusting  the  blade  at 
the  bifurcation  of  the  roots  and  giving 
the  end  of  the  chisel  a  blow  with  the 
mallet  sufficient  to  separate  the  parts. 
It  is  also  used  in  a  case  where  the  crown 
of  the  inferior  third  molar  is  decayed  on 
its  mesial  surface  and  impinges  on  the 


Fig.  41. — Mastoid  Cliisel.  For 
separating  roots  and  re- 
moving mesial  contact 
point  of  decayed  impacted 
inferior  tiiird  molar. 


54 


INSTRUMENTS 


V 


crown  of  tlie  second  molar,  and  the  impinging  part  is  to  be  cut 
away.     It  is  sometimes  used  as  a  substitute  for  the  bur,  and  is 

especially  applicable  when  a 

patient   is   under   a   general 

anesthetic  and  the  operator 

wishes  to  get  quick  results. 

The  chisel  may,  in  addition, 

l)e   used    for    an    occasional 

operation  on  an  inferior  an- 
terior tooth  when  displaced 

to    the   lingual   side   of   the 

arch. 


INSTRUMENTS  FOR 
EXAMINATION. 

As  no  operation,  however 
simple,  should  be  begun 
without  a  careful  examina- 
tion of  the  parts,  it  is  neces- 
sary that  provision  be  made 
for  this  preliminary.  The 
instruments  commonly  used 
for  this  operation  are  the 
mouth  mirror,  foil  carrier, 
explorer,  and  probe. 

Mouth  Mirror. — The  mouth 
mirror  (Fig.  42)  is  used  for 
making  all  preliminary  ex- 
aminations. The  important 
features  are  a  good  magni- 
fying lens,  to  insure  a  true 
reflection;  a  water-proof  set- 
ting to  allow  of  sterilization; 
and  a  handle  of  such  length 
that  all  parts  of  the  mouth 
can  be  readily  examined 
with  it. 

Foil  Carrier. — The  foil  car 
rier     (Fig.    43)     should    be 


Fig.  42. — Mouth  Mir- 
ror. For  making'  ex- 
aminations in  the 
oral  cavity. 


Fig.  43. — Foil  Carrier. 
For  carrying  and 
removing  dre.ssing. 
removing  foreign 
bodies,  and  for  all 
purposes  requiring 
light  tweezers. 


INSTRUMENTS  FOR  EXAMINATION 


55 


practically  universal  in  its  use.  One  not  over  six  inches  in 
length,  made  of  good  spring  steel,  and  with  the  points  at  an 
angle  of  about  forty-five  degrees  with  the  axis  of  the  handle, 
is  most  suitable.  It  is  used  for  carrying  pledgets  of  cotton 
or  other  material,  for  wiping 
away  debris  from  parts  to  be 
examined,  and  for  removing 
any  small  bodies  from  around 
the  teeth. 

Explorer.— A  small  selection 
of  explorers  should  be  pro- 
vided. As  the  points  of  these 
instruments  are  delicate,  they 
should  be  made  of  properly 
tempered  steel,  and  the  handles 
should  be  of  metal  to  permit  of 
ready  sterilization.  The  in- 
strument shown  in  Fig.  44  is 
a  very  practical  explorer,  and 
almost  universal  in  application 
to  the  teeth. 

Probe.— The  probe  (Fig.  45) 
is  made  of  a  single  piece  of 
slender  metal,  with  a  blunt 
point.  It  is  used  to  ascertain 
the  position  of  a  tooth  or  root 
that  is  imbedded  in  or  over- 
grown with  soft  tissue,  or  to 
determine  the  condition  of  any 
osseous  structures  not  exposed 
to  view.  With  practice  the 
operator  will  be  able  to  dis- 
tinguish between  tooth  struc- 
ture and  the  alveolar  process^ 
as  the  former  is  slightly  mobile 
when  pressed,  and  the  point  of 
the  probe  will  slide  along  the 
surface  instead  of  penetrating, 
while  the  latter  is  rough,  immo- 


Fig-.  44.— Explorer.  For 


examining  teeth  and    i,;i^        „j  t      j  jii 

alveolar  process.       bile,  and  somcwliat  penetrable. 


g'.  45. — Probe.  For 
examining  osse- 
ous tissue  and  ex- 
ploring sinuses. 


CHAPTER  III. 

OFFICE  EQUIPMENT. 

The  office  arrangement  should  consist  of  an  operating,  recep- 
tion, and  rest  room,  each  separated  from  the  other  and  contain- 
ing respectively  such  equipment  as  will  facilitate  the  work  of 
the  operator  and  conduce  to  the  comfort  of  the  patient.  The 
nature  of  the  work  demands  absohite  cleanliness,  and  the  efpiip- 
ment  should  he  of  a  character  to  conform  to  strictly  sanitary 
requirements. 

OPERATING  ROOM. 

The  extraction  of  teeth  should  he  performed  in  a  room  specially 
arranged  for  that  puri)ose.  It  is  not  necessary  that  the  room 
be  very  large,  a  room  nine  l)y  ten  feet  being  of  ample  size.  The 
floor  should  be  of  white  floor  tile,  with  a  tile  or  marble  baseboard. 
The  walls  should  be  tinted  or  painted,  so  that  they  can  be 
washed,  and,  of  all  colors,  white  deserves  ]ireference.  because 
any  blood  carried  to  the  walls  can  then  lie  noticed  and  removed 
quickly,  while  on  any  other  color  blood  spots  or  other  foreign 
matter  are  not  so  easily  seen,  and  are  thus  allowed  to  dry  and 
accumulate,  thereby  affording  excellent  means  for  the  distribu- 
tion of  bactei'ia.  For  the  purpose  of  minimizing  the  possibility 
of  harboring  bacteria,  window  curtains  and  all  other  forms  of 
drapery,  bric-a-brac,  wall  pictures,  and  all  furniture,  except  such 
as  forms  part  of  the  office  equipment,  should  be  excluded  from 
the  room. 

The  location  of  the  window  and  operating  chair  should  be  in 
such  relation  to  each  other  as  to  secure  a  good  light  for  the 
operator,  with  just  enough  space  between  the  window  and  chair 
for  the  patient  to  freely  enter  and  leave  the  chair. 

The  operating  room  should  be  a  convenient  distance  from  the 
reception  room,  so  that  if  a  patient  cries  out  during  the  opera- 
tion, as  is  sometimes  the  case,  especially  when  under  a  general 
anesthetic,  it  will  not  cause  the  patients  in  waiting  to  become 

56 


OPERATING  ROOM  57 

nervous  or  to  feel  apprehensive  in  regard  to  their  behavior  dur- 
ing the  operation  to  be  performed  on  them. 

Operating  Chair. — The  o])erating  chair  mnst  l)e  strongly  built 
and  stationary,  but  need  not  necessarily  be  as  high  grade  a  chair 
as  is  used  for  other  dental  operations.  A  practical  chair  for  this 
operation  is  a  Morrison,  because  it  can  be  adjusted  to  high  and 
low  positions,  and  its  mechanism  is  extremely  simple.  The  one 
objectionalile  feature — that  of  raising  or  lowering  it  with  a  crank 
— is  not  worth  considering  in  view  of  the  advantage  gained  by 
the  positions  that  can  be  obtained  with  it  and  the  severe  usage 
to  which  it  can  be  subjected.  Many  operators  prefer  the  old 
Archard  chair,  in  which  the  patient  sits  very  comfortably,  and 
in  giving  nitrous  oxid  and  oxygen  this  chair  has  the  advantage 
of  not  allowing  the  patient  to  slide  out  of  it  so  readily  in  case 
there  is  any  struggling.  C^hairs  of  the  newer  types  are  also 
practical  and  have  many  good  points. 

Foot-Stand. — A  small  box  or  platform,  for  the  operator  to 
stand  on,  will  be  found  a  convenient  accessory  when  operating 
on  the  inferior  teeth.  It  should  be  about  twelve  by  twelve  inches 
square  and  from  six  to  twelve  inches  in  height,  according  to  the 
stature  of  the  operator.  The  use  of  such  box  will  enable  the 
operator  to  obtain  direct  access  to  the  field  of  operation  while 
standing  behind  the  patient  and  operating  on  the  inferior  teeth. 
AVlien  not  in  use,  the  box  should  be  placed  back  of  the  chair,  so 
that  it  can  be  readily  and  unobtrusively  shoved  into  position 
with  the  foot  when  needed.  It  is  advisal)le  to  cover  the  box, 
both  on  the  upper  and  lower  surfaces,  with  rubber  matting,  so 
as  to  prevent  slipping  of  the  operator  on  the  box  or  the  box 
sliding  on  the  floor,  and  this  precaution  will  also  render  it 
noiseless.  ^  '  •' 

Cabinet. — Next  in  importance  is  a  suitable  cabinet.  Cabinets 
are  constructed  either  of  wood  or  metal.  The  author  prefers  one 
made  of  wood,  as  the  doors  and  drawers  can  be  made  to  fit 
closer,  thereby  better  excluding  the  dust.  White  enamel  makes 
a  good  finish  for  such  a  cabinet.  The  top  should  be  covered  with 
a  heavy  piece  of  plate-glass,  which  will  serve  as  a  suitable  shelf 
on  which  to  place  instruments,  receptacles  for  antiseptic  solu- 
tions, etc.,  and  blood  or  other  foreign  matter  can  be  easily  re- 
moved from  a  glass  surface.  The  upper  compartment  consists 
of  drawers  whose  bottoms  are  covered  with  glass,  and  these  will 


58  OFFICE  EQUIPMENT 

be  convenient  receptacles  for  props,  forceps,  elevators,  and  such 
instruments  as  are  nsed  in  the  extraction  operation.  This  ar- 
rangement has  the  advantage  of  having  the  instruments  readily 
accessible  and  at  the  same  time  out  of  sight  of  the  patient,  as 
any  unnecessary  display  of  instruments  will  affect  the  average 
patient  and  render  him  less  amenable  to  control.  Below  this  tier 
of  drawers  are  compartments  for  clean  linen.  The  cabinet  should 
be  located  on  a  line  with  and  to  the  right  of  the  operating  chair, 
leaving  space  enough  for  tlie  operator  to  readily  pass  between 
the  chair  and  the  cabinet.  It  will  be  found  a  good  habit  to  keep 
the  instruments  in  definite  arrangement  and  to  thoroughly  famil- 
iarize oneself  with  this  arrangement.  This  will  enable  the, oper- 
ator to  lay  his  hand  on  any  instrument  needed  without  removing 
his  eyes  from  the  field  of  operation  and  without  unnecessary  loss 
of  time. 

Sterilizing  Vase. — A  small  sterilizing  vase  is  used  for  the  re- 
ception of  the  mouth  mirror,  probe,  and  such  instruments  of 
general  use  that  should  always  be  sterilized  before  putting  them 
into  the  mouth.  The  sterilizing  vase  is  much  better  for  this 
purpose  than  a  drinking  glass,  which  is  so  often  used. 

Cuspidor. — A  fountain  cuspidor,  placed  beside  the  operating 
chair,  is  indispensable.  Tt  is  preferable  not  to  have  the  cuspidor 
attached  to  the  chair,  especially  when  a  general  anesthetic  is 
employed,  for,  should  the  patient  struggle,  he  would  possibly  do 
damage  to  himself  or  the  cuspidor,  or  to  both.  Such  a  cuspidor 
is  fitted  with  an  extension  bracket,  so  that  it  can  be  moved 
forward,  l^ackward,  or  laterally.  The  bracket  holding  the  cus- 
pidor should  be  firmly  attached  to  the  wall,  in  front  and  about 
a  foot  to  the  left  of  the  center  of  the  chair.  During  the  operation 
the  cuspidor  is  shoved  back  to  the  wall  and  well  out  of  the  way, 
but  can  be  readily  swung  over  to  the  patient  immediately  on 
completion  of  the  extraction.  It  should  be  kept  scrupulously 
clean,  free  of  all  traces  of  blood  from  any  previous  operation,  and 
always  in  readiness  for  use. 

Pus  Pan. — An  accessory  to  the  cuspidor  is  a  small  pan,  such  as 
is  used  by  surgeons  and  known  as  a  pus  pan.  It  is  held,  when 
its  use  is  necessary,  under  the  chin  by  the  assistant.  Into  this 
pan  the  patient  expectorates  the  l)lood  immediately  after  the 
operation  and  while  recovering  from  the  anesthetic,  or  is  used 
when  a  patient  is  very  heavy  and  cannot  readily  bend  over  to 


OPE  RATING  ROOM  59 

the  cuspidor.  A  pan  of  this  character  will  also  serve  as  a  recep- 
tacle for  extracted  teeth,  cotton,  and  month  props,  and  can  be 
used  to  take  away  the  instrnments  employed  in  the  operation. 

Artificial  Light. — A  good  sonrce  of  artificial  light  is  essential, 
as  frequently  a  diagnosis  or  an  operation  must  be  undertaken  at 
night  or  on  a  dark  day.  The  best  method  of  obtaining  suitable 
artificial  illumination  for  this  purpose  has  always  been  a  prob- 
lem. The  majority  of  lamps  designed  for  dental  work  throw  a 
strong  beam  of  light,  intended  to  be  focused  into  the  mouth; 
but,  should  the  patient's  head  be  moved,  the  field  of  operation 
is  obscured — perhaps  just  at  the  moment  when  light  is  most 
needed  and  when  it  is  inconvenient  to  disengage  the  hands  for 
its  readjustment.  The  Rhein  light,  designed  by  Dr.  M.  L.  Rhein, 
offers  a  satisfactory  solution  of  this  problem.  Its  construction 
permits  it  to  be  easily  raised  or  lowered,  and  it  should  be  so 
suspended  as  to  hang  about  one  foot  in  front  of  the  chair. 

Nitrous  Oxid  Apparatus. — The  apparatus  for  the  administra- 
tion of  nitrous  oxid  and  oxygen  should  be  conveniently  located 
on  the  left  side  of  the  chair,  and  slightly  in  front  or  to  the  rear. 
The  apparatus  should  be  simple  in  construction,  so  that  it  can  be 
easily  kept  in  working  condition,  and  allow  any  part  that  may 
become  contaminated  to  be  easily  detached  for  sterilization. 
Scrupulous  care  in  keeping  all  parts  in  order  will  avoid  accidents 
while  operating. 

Dental  Engine. — Some  form  of  dental  engine,  of  either  foot  or 
electric  power,  together  with  a  selection  of  burs,  should  be  kept 
within  easy  reach  of  the  operator.  It  may  be  needed  to  remove 
the  alveolar  process  from  around  a  fractured  root,  for  cutting 
away  parts  of  an  impacted  tooth  and  the  osseous  structure  about 
such  a  tooth,  or  for  liurring  out  roots  which  cannot  be  extracted 
])y  other  methods. 

Sterilizer. — The  advance  in  bacteriologic  science  has  proved 
conclusively  that  a  simple  cleaning  of  the  instruments  does  not 
free  them  from  pathogenic  bacteria,  and  that  in  addition  to  the 
cleaning  they  must  be  thoroughly  sterilized  in  order  to  avoid 
possible  infection  and  prevent  the  transmission  of  disease.  No 
instrument  that  is  not  surgically  clean  should  be  introduced  into 
the  mouth,  and  no  modern  operator  should  l)e  guilty  of  such 
gross  neglect  as  operating  with  unsterilized  instruments,  for  by 
such  conduct  he  would  be  doing  injustice  to  himself  and  probable 


60  OFFICE  EQUIPMENT 

injury  to  his  patients.  The  simplest  form  of  sterilization  is  by 
heat,  and  this  is  preferably  done  with  water  as  the  medinm. 
Any  receptacle  into  which  the  instruments  can  be  placed  will 
serve  the  purpose.  There  are  many  varieties  of  sterilizers  from 
which  to  select.  A  simple  and  practical  one  consists  of  an 
ordinary  tank,  made  of  copper  and  nickeled,  fitted  with  one  or 
more  wire  screen  trays  with  which  to  carry  the  instruments  into 
and  out  of  the  hot  water.  The  water  may  be  heated  by  any  con- 
venient means,  such  as  alcohol,  gasoline,  gas,  or  electricity.  A 
simple  means  of  procedure  is  to  thoroughly  cleanse  the  instru- 
ments immediately  on  completion  of  the  operation,  after  which 
they  are  placed  into  the  tray,  lowered  into  the  sterilizer,  and 
allowed  to  boil  for  several  nimutes.  They  are  then  removed 
from  the  sterilizer,  thoroug'hly  dried,  and  put  into  their  proper 
places  in  the  operating  cabinet,  A  small  amount  of  bicarbonate 
of  soda  added  to  the  water  in  the  sterilizer  will  prevent  tarnish- 
ing of  the  instruments.  As  a  further  precaution,  before  pro- 
ceeding with  the  next  operation,  the  instruments  should  be  placed 
for  a  time  in  alcohol  or  a  strong  solution  of  lysol,  which  should 
always  be  kept  in  some  convenient  place  in  the  cabinet.  Plain 
aseptic  gauze,  which  should  be  ke])t  in  a  close-fitting  receptacle, 
will  serve  as  a  convenient  method  for  removing  any  surplus 
solution  remaining  on  the  instrument.  Most  cases  of  pain  or 
inflammation  after  extraction  are  attributed  by  the  patient  to 
the  neglect  of  the  operator,  and  the  claim  is  invariably  made  in 
such  instances  that  he  has  used  unclean  or  "dirty"  instruments. 
Sterilization  is  so  simple  that  any  operator  should  be  able  to 
exonerate  himself  of  such  charge. 

Toilet  Accessories. — A  lavatory  should  be  placed  in  the  opera- 
ting room,  so  as  to  be  readily  accessible  to  l)oth  operator  and 
assistant.  Foot-pedals  for  operating  the  faucets  will  be  found 
a  great  convenience  in  the  cleansing  of  the  hands,  as  the  water 
supply  can  then  be  regulated  without  the  hands  coming  in  con- 
tact with  the  faucets. 

A  sanitary  vSoap  receptacle,  containing  liquid  soap,  is  cleanly, 
for  by  its  use  soap  may  be  applied  to  the  hands  without  contami- 
nating the  remainder  with  blood  or  other  matter,  as  is  frequently 
done  when  using  ordinary  cake  soa|). 

Scrub  brushes  should  be  kept  in  a  tray  that  can  be  readily 
cleaned,  and  the  brushes  should  be  sterilized  repeatedly. 


CARE  OF  PATIENT  61 

Another  modern  and  sanitary  convenience  is  a  glass  shelf  con- 
nected with  the  lavatory,  on  which  a  number  of  clean  drinking- 
glasses  (inverted)  and  a  supply  of  individual  fiber  drinking-cups 
should  be  kept. 

With  a  room  equipped  in  the  manner  described,  the  operator 
will  find  himself  in  a  position  to  efficiently  attend  to  any  ordinary 
case,  giving  the  greatest  satisfaction  to  himself  and  comfort  to 
the  patient. 

CARE  OF  THE  PATIENT. 

A  well-appointed  office  should  include,  in  addition  to  the  oper- 
ating room,  a  reception  room  and  at  least  one  rest  room. 

Reception  Room. — The  first  impression  received  by  the  patient 
goes  far  toward  inspiring  his  confidence,  or  causing  a  lack  of  it, 
in  the  operator.  A  neat,  clean,  and  artistically  arranged  recep- 
tion room  will  usually  make  the  first  impression  a  favorable  one, 
and  may  be  a  simple  means  of  establishing  a  good  reputation  with 
a  patient,  which  will  be  one  of  the  best  assets  of  the  operator 
during  his  future  years  of  practice.  Taste  in  the  selection  of 
the  furniture,  rugs,  and  decorations,  aspiring  to  a  harmonious 
tout- ensemble,  will  be  found  to  amply  repay  the  practitioner  for 
the  expenditure  of  thought,  time,  and  money.  A  few  magazines, 
neatly  arranged  on  a  table,  covering  a  range  of  subjects  likely  to 
interest  au}^  grade  of  intelligence,  may  pleasantly  engage  the 
mind  of  the  waiting  patient  and  divert  his  thoughts  from  the 
approaching  operation. 

Rest  Room. — The  rest  room  should  be  conveniently  located, 
and  contain  a  couch  and  an  easy-chair,  with  a  fountain  cuspidor 
so  placed  as  to  swing  readily  in  any  direction.  Additional  fur- 
nishings may  consist  of  one  or  more  chairs  for  the  friend  who 
may  wish  to  remain  with  the  patient  during  the  recovery.  A 
clothes-rack  should  be  supplied,  on  which  the  patient's  wraps 
may  be  placed  previous  to  entering  the  operating  room,  and  also 
a  dressing  table  with  a  mirror,  together  with  such  toilet  requi- 
sites as  are  in  connnon  use.  While  the  relief  aiforded  to  most 
patients  by  the  operation  is  such  that  they  do  not  care  to  linger, 
the  state  of  health  of  others  demands  that  a  short  period  of  rest 
follow  the  operation.  For  the  latter  a  time  spent  in  the  rest 
room  will  often  restore  the  strength  and  quiet  the  nervous  sys- 
tem, thereby  adding  greatly  to  the  success  of  the  operation. 


62  OFFICE  EQUIPMENT 

Attendant.^ — To  relieve  the  operator  of  much  of  the  daily  rou- 
tine, and  allow  him  to  devote  more  of  his  time  to  the  professional 
j)art  of  his  practice,  a  well-trained  lady  attendant  is  invaluable. 
She  receives  the  patient  when  he  arrives,  looks  after  his  comfoii;, 
and  makes  him  feel  at  ease  while  awaiting  his  turn  for  the  opera- 
tion. She  takes  the  name  of  the  patient  to  the  operator,  and  con- 
veys any  other  information  that  may  be  helpful  in  the  work  that 
is  to  be  done.  If  it  is  a  former  patient,  the  records  are  consulted, 
and  such  characteristics  or  idiosyncrasies  as  may  be  peculiar  to 
the  patient  are  carefully  noted.  In  the  operating  room  she  seats 
the  patient  in  the  chair,  arranges  the  linen  for  the  protection  of 
the  clothing  from  blood  stains,  and  helps  in  soothing  and  encour- 
aging timid  patients,  the  latter  attention  being  given  particularly 
to  children  and  to  aged  and  nervous  persons.  During  the  opera- 
tion she  keeps  the  arms  of  the  patient  from  interfering  with  the 
operator,  hands  the  inhaler  to  the  operator  when  nitrous  oxid 
and  oxygen  is  administered,  opens  and  closes  the  valve  of  the 
apparatus,  sees  that  the  patient's  mouth  is  kept  open,  and  uses 
the  mouth-gag  when  necessary.  She  should  always  be  alert  to 
hand  the  oj)erator  such  accessories  as  he  may  require,  so  that  he 
does  not  have  to  take  his  eyes  from  the  field  while  operating.  As 
far  as  possible  she  should  keep  the  operating  area  clear  of  blood 
by  swabbing,  and  catch  all  teeth  that  may  be  extracted.  After 
the  operation  is  completed  she  holds  a  pan  under  the  chin  while 
the  patient  is  recovering  from  the  anesthetic,  hands  the  patient 
sterilized  water  for  rinsing  the  mouth,  and  extends  whatever 
little  courtesies  the  patient  should  receive.  Before  proceeding 
with  the  next  operation,  the  attendant  rearranges  the  operating 
room,  sterilizes  all  the  instruments  that  may  have  been  used 
and  restores  them  to  their  proper  places,  and  removes  all  traces 
of  the  preceding  operation,  so  that  the  patient  following  will 
not  be  made  to  feel  uneasy  by  any  suggestive  sights.  "With  a 
competent  attendant  i^roperly  discharging  these  details,  the 
operator  can  give  his  undivided  time  and  attention  to  the  opera- 
tive procedure. 


CHAPTER  IV. 
ANATOMICAL  LANDMARKS. 

The  operator  should  possess  a  thorough  knowledge  of  the 
anatomy  of  the  teeth  and  surrounding  parts.  This  is  especially 
true  in  regard  to  the  anatomy  of  the  teeth  in  their  relation  to  the 
bony  walls  which  retain  them.  To  emphasize  the  importance  of 
this  statement,  as  well  as  to  serve  as  a  sort  of  ready  reference, 
and  especially  to  make  clear  the  extraction  movements  which  are 
described  in  the  chapters  on  extraction  teclmic,  a  few  illustra- 
tions are  shown  to  present  the  general  arrangement  of  the  teeth 
and  alveolar  process.  The  illustrations  presented  may  differ 
somewhat  from  the  stereotyped  ones  frequently  found  in  works 
on  anatomy,  but  they  are  about  as  correct  as  can  be  obtained,  and 
are  sufficiently  plain  to  form  a  basis  for  the  study  of  the  anatomy 
of  these  parts;  for,  while  the  bodily  structure  of  different  individ- 
uals is  by  no  means  uniform,  its  analogy  to  a  prevailing  form  will 
convey  a  clear  conception  of  the  anatomy  peculiar  to  any  part, 
and  variations  from  the  common  standard  must  be  noted. 

DENTO-OSSEOUS  STRUCTURES. 

Labially. — Fig.  46  shows  an  anterior  view  of  an  almost  nor- 
mally articulated  set  of  teeth.  Attention  is  directed  to  the  heavy 
bony  structure  over  the  superior  cuspids  (canine  eminence),  and 
the  height  to  which  it  extends  above  the  alveolar  ridge  as  com- 
pared with  that  over  the  central  and  lateral  incisors.  The  diame- 
ter of  the  roots  of  the  superior  lateral  incisors  is  much  less  than 
that  of  the  roots  of  the  teeth  on  either  side  of  them.  This  pecu- 
liarity should  be  taken  into  consideration  when  studying  the 
process,  as  it  is  deceptive,  for,  instead  of  being  weak,  it  in  reality 
possesses  greater  strength  in  proportion  to  the  strength  of  the 
roots  than  that  overlying  the  roots  of  either  the  cuspids  or  cen- 
trals. The  superior  central  incisors  are  situated  in  close  prox- 
imity to  the  suture  uniting  the  right  and  left  maxilhe,  which  is  a 
matter  of  prime  importance  to  the  operator  when  the  develop- 

63 


64 


ANATOMICAL  LANDMARKS 


ment  of  bone  lias  not  been  complete  in  this  region,  as  in  a  case 
of  cleft  palate.  A  comparison  of  the  convolutions  of  the  jn-ocess 
over  the  six  superior  anterior  teeth  with  the  antero-posterior 
diameter  of  their  necks  will  indicate  the  rotundity  of  their  roots, 
and  serve  as  a  guide  to  the  amount  of  rotatory  movement  that 
may  be  exercised  in  their  extraction.  The  interproximal  spaces 
between  the  ten  inferior  teeth,  considered  in  relation  to  the  ex- 
ternal i^late  of  the  process,  gives  a  fair  outline  of  their  roots. 


46. — An  almost  perfect   set   of  teeth.     Anterior  view,    showing  teeth  and   osseous 

structure. 


Buccally. — Fig.  47  shows  a  side  view  of  the  same  skull  shown 
in  Fig.  4().  In  this  region  attention  is  directed  to  the  process 
over  the  superior  first  bicuspid,  as  it  outlines  with  reasonable 
accuracy  the  root  formation  of  this  tooth.  A  narrow  ridge,  be- 
ginning near  the  gum  margin  and  extending  well  up,  indicates 
a  bifurcation  throughout  the  greater  part  of  the  root's  length; 
a  comparatively  even  process  near  the  margin,  with  a  sharp  pro- 
jection high  up,  indicates  a  bifurcated  apex  and  probably  some 
divergence,  while  lack  of  prominence  to  the  ridge  indicates  a 
single-rooted  tooth.  The  superior  first  molar  is  directly  in  line 
with  the  ridge,  which,  beginning  in  the  cortical  part  of  the  proc- 


DENT0-088E0U8  STRUCTURES 


65 


ess  at  this  point,  extends  upward  to  form  the  malar  process  of 
the  superior  maxilla.  There  is  much  variation  in  the  origin  of 
this  ridge.  If  it  begins  low,  it  always  adds  much  to  the  strength 
of  the  buccal  plate  of  the  process,  making  it  dense  and  rigid, 
while  greater  distance  between  the  alveolar  margin  and  the  ridge 
indicates  a  more  flexible  process.  The  malar  process  of  the  supe- 
rior maxilla  is  always  to  be  observed  in  connection  with  the  teeth, 
as  is  also  the  process  covering  the  roots  of  the  second  bicuspid 
and  first  molar,  to  determine,  if  possible,  the  relation  of  the  roots 
of  these  teeth  to  the  floor  of  the  maxillarv  sinus.     The  width  of 


Fig.  47. — Same  subject  as  Fig.   46.     Side  view,  showing  teeth  and  osseous  structure. 


the  buccal  plate  of  the  alveolar  process  in  the  region  of  the  in- 
ferior bicuspids  and  molars  is  subject  to  the  usual  variations  that 
are  common  to  the  bony  structures  about  the  mouth,  and  such 
variations,  when  studied  in  conjunction  with  these  teeth,  present 
the  usual  points  for  determining  the  strength  of  these  structures, 
which  are  always  of  interest  to  the  operator. 

Palatally. — Fig.  48  shows  the  occlusal  surfaces  of  the  superior 
teeth  ill  situ,  the  lingual  plate  of  the  process  supporting  them,  the 
palatal  bones,  and  the  palatal  processes  of  the  superior  maxilla. 
These  combined  structures  form  the  palatal  arch,  which  varies 


66 


ANATOMICAL  LANDMARKS 


Fig.  48. — Same  subject  as  Figs.   4G,   47.     View  of  supciior  aidi,   sliuwinii-  ii-rxh  and 

osseous  structure. 


Fig.  49. — Same  subject  as  Figs.  46,  47,  48.     View  of  inferior  arch,  showing  teeth  and 

osseous  structure. 


DENT0-0S8E0U8  STRUCTURES 


67 


mucli  in  form  and  height.  A  high  vault  indicates  a  wide  cortical 
plate  of  the  alveolar  process,  and  such  a  plate  is  usually  thinner 
than  the  narrow  plate  found  with  the  low  vault.  The  thin  wide 
plate  is  more  flexible  than  the  narrow  one,  and  forms  a  less  firm 
supporting  wall  for  the  teeth. 

Variation  in  the  superior  arch  reaches  its  maximum  in  the 
region  of  the  third  molars,  and  such  variations  are  always  to  be 
studied  in  connection  with  these  teeth.     These  tuberosities  are 


Fig-.  50. — Superior  and  inferior  arch.     Anterior  view,  showing  tlie  roots  of  the  teeth. 


poorly  supported,  being  the  termini  of  the  arch,  and,  at  best, 
present  an  element  of  weakness  that  should  always  be  given  due 
consideration. 

Lingually. — Fig.  49  shows  an  upper  view  of  a  mandible,  with 
all  the  teeth  in  normal  position,  and  exhibits  the  distal  half  of 
the  third  molars  situated  lingually  to  the  anterior  edge  of  the 
ascending  rami.  The  alveolar  process  surrounding  these  teeth 
is  almost  entirely  lacking  on  their  buccal  sides,  the  development 
of  process  consequent  to  their  eruption  being  confined  almost 


68 


ANATOMICAL  LANDMARKS 


wholly  to  the  lingual  side.  The  alveolar  process  supporting  the 
inferior  incisors  differs  from  that  supporting  any  of  the  other 
teeth  in  that  it  has  a  greater  labio-lingual  diameter  near  its  edge 
than  it  has  well  up  on  the  roots  of  these  teeth. 

ROOTS  OF  THE  ANTERIOR  TEETH. 

Fig.  50  shows  an  anterior  view  of  the  upper  and  lower  jaws, 
with  the  cortical  plate  of  the  process  removed,  revealing  the 


Fig.  51. — Same  subject  as   Fig.   50.     Side  view,  showing  the  roots  of  the  teeth. 

roots  of  the  teeth.  The  illustration  shows  not  only  the  position 
of  the  roots  in  the  cancellous  structure  of  the  process,  but  also 
their  relation  to  each  other. 


ROOTS  OF  THE  POSTERIOR  TEETH. 

Fig.  51  shows  a  side  view  of  the  same  skull.  Attention  is 
directed  to  the  distal  inclination  of  the  roots,  and  also  to  the 
wide  variation  in  the  form  of  the  roots  of  the  inferior  molars. 


IMPORT  OF  ANATOMICAL  LANDMARKS  69 

IMPORT  OF  ANATOMICAL  LANDMARKS. 

Dental  anatomy,  from  the  standpoint  of  the  exodontist,  should 
be  studied  in  the  light  of  mechanics  in  addition  to  that  of  descrip- 
tion, for  the  extraction  of  a  tooth — whether  by  forceps,  elevator, 
screw-porte,  or  whatever  means  may  be  chosen — is  only  the  sepa- 
rating from  each  other  of  parts  that  have  been  united  in  the 
development  of  the  jaws.  To  the  exodontist,  then,  the  landmarks 
of  mechanical  strength  are  of  the  same  import  as  are  the  land- 
marks of  surgery  to  the  surgeon.  Indeed,  he  can  have  no  greater 
asset  than  to  be  able  to  determine  with  reasonable  accuracy  the 
amount  and  direction  of  force  required  in  the  application  of  the 
instrument  and  in  the  execution  of  the  extraction  movements  for 
the  delivery  of  a  tooth  from  its  attachment  in  each  particular 
case,  as  the  variations  to  be  met  as  well  as  the  different  condi- 
tions presented  are  practically  unlimited. 


CHAPTER  V. 

INDICATIONS  AND  COUNTERINDICATIONS  FOE 
EXTRACTION. 

Indications  and  counterindications  for  extraction  are  governed 
by  the  extent  of  the  caries  involving  the  tooth,  its  nerve  and 
blood  supply,  the  condition  of  its  roots  and  associated  tissues, 
its  relation  to  the  other  teeth  (occluding  and  approximating)  and 
to  the  surrounding  structures,  its  further  usefulness  as  a  natural 
or  restored  organ,  traumatic  injuries,  chronic  and  surgical  dis- 
eases (local  or  systemic),  and  the  general  health  of  the  patient. 

CONDITIONS  THAT  INDICATE  EXTRACTION. 

It  is  impossible  to  formulate  a  definite  list  of  cases  in  which  ex- 
traction is  indicated,  as  the  varying  conditions  to  be  met  are  too 
numerous  for  a  set  of  rules  that  would  apply  to  all  cases.  Unless 
counterindicated  by  individual  conditions,  surgical  interference 
is  indicated  in  all  cases  where  the  tooth  is  affected  by  caries  to 
such  an  extent  that  the  lost  function  cannot  be  restored. 

Pathologic  Conditions. — Other  pathologic  conditions  that  indi- 
cate extraction  are  as  follows: 

1.  Where  there  is  extensive  loss  of  alveolar  process,  so  that 
the  tooth  is  no  longer  held  firmly  in  position,  the  consequent 
luxation  causing  inflammation  of  the  surrounding  tissue,  which 
cannot  be  relieved  by  treatment  or  appliance. 

2.  "Where  a  tooth  is  involved  in  necrosis  of  the  alveolar  proc- 
ess, and  its  retention  may  endanger  the  peridental  membrane  of 
the  tooth  adjacent  to  the  affected  one  or  the  periosteum  of  the 
maxilla. 

3.  Where  a  tooth  causes  an  acute  alveolar  abscess,  with  diffu- 
sion, and  the  delay  required  in  an  attempt  to  save  the  organ  may 
result  in  a  general  infectious  process. 

4.  Where  a  tooth  causes  a  chronic  alveolar  abscess  that  is  not 
amenable  to  treatment,  and  its  retention  may  cause  a  gradual 
breaking  down  of  the  surrounding  tissues,  or  endanger  the  gen- 
eral health  by  the  constant  absorption  of  pus. 

70 


CONDITIONS  THAT  INDICATE  EXTRACTION  71 

5.  Where  an  affected  tootli  involves  the  lymphatic  glands,  and 
its  sacrifice  is  preferable  to  an  nncertain  termination  of  the  con- 
dition. 

6.  Where  a  tooth  with  infected  or  putrescent  pnlp  tissue  is  the 
source  of  a  disturbance,  and  a  constricted  or  crooked  canal  pre- 
vents proper  treatment. 

7.  Where  the  pulp  of  a  tooth  is  encroached  upon  by  pulpstones, 
and  relief  can  be  obtained  only  by  extraction. 

8.  Where  there  is  absorption  of  the  apex  of  the  root,  and  its 
resection  is  not  practicable  or  has  been  a  failure. 

9.  Where  a  tooth  has  a  perforated  pulp  chamber  or  root,  whose 
closure  by  artificial  means  causes  chronic  irritation. 

10.  Where  a  tooth  causes  a  dental  cyst,  or  where  a  superior 
second  bicuspid  or  first  molar  discharges  pus  into  the  maxillary 
sinus,  and  the  conditions  can  be  remedied  only  by  extraction. 

11.  Wliere  the  irritation  of  a  tooth  causes  a  simple  or  malig- 
nant epulis. 

12.  Where  the  lesion  of  a  tooth  is  a  source  of  irritation  or  pain, 
and  the  general  health  of  the  patient  prevents  alleviation. 

Impacted  Teeth. — A  tooth  that  is  partially  or  completely  im- 
pacted and  impinges  on  another  tooth,  which  condition  cannot 
be  corrected  by  other  means,  and  esj^ecially  where  the  pressure 
of  the  tooth  on  another  tooth  or  the  associated  tissues  is  causing 
constant  irritation  and  there  is  danger  of  a  general  systemic  dis- 
turbance, should  be  extracted. 

Supernumerary  Teeth. — A  supernumerary  tooth  that  is  of  no 
practical  value,  or  where  it  interferes  with  the  proper  eruption 
of  the  normal  teeth,  thereby  causing  irregularties,  or  where 
such  tooth  causes  irritation  of  the  surrounding  tissues,  should 
be  extracted. 

Malposed  Teeth. — A  tooth  out  of  alignment  with  the  arch, 
where  the  condition  cannot  be  corrected  by  the  orthodontist  or  by 
artificial  restoration,  should  be  extracted  if  he  so  advises.  An 
abnormally  shaped  tooth,  with  a  crown  that  serves  no  practical 
purpose  and  is  detrimental  to  the  features,  should  be  extracted. 
A  tooth  that  has  no  occluding  antagonist,  or  is  elongated  and 
irritates  the  tissues  of  the  opposing  jaw  or  other  soft  tissues, 
should  be  extracted. 

Fractured  Teeth. — Where  the  root  of  a  tooth  is  fractured  to 
such  an  extent  that  it  cannot  be  repaired  by  an  artificial  crown 


72  INDICATIONS  AND  C0UNTERINDICATI0N8 

or  by  some  other  method,  or  where  a  tooth  that  contains  a  large 
filling  is  fractured  so  that  it  involves  the  roots  in  such  manner 
that  they  cannot  be  again  made  serviceable,  extraction  is  indi- 
cated. 

Roots  Supporting  Crown  or  Bridge. — Eoots  that  support  a 
crown  or  serve  as  the  abutment  for  a  bridge  should  be  extracted 
when  loosened  through  some  pathologic  condition  of  the  support- 
ing tissues  that  will  not  yield  to  treatment,  and  the  resultant 
mobility  is  injurious  to  adjacent  teeth  or  to  the  general  health, 
or  when  these  roots  are  fractured  so  that  their  usefulness  in  re- 
taining an  artificial  crown  is  destroj^ed. 

Artificial  Dentures.^ — AVhere  a  tooth  is  in  such  position  that  it 
is  not  serviceable  for  either  mastication  or  for  the  retention  of 
an  artificial  denture,  but  may  interfere  with  the  articulation  or 
adai^tation  of  the  denture,  extraction  is  indicated. 

Deciduous  Teeth. — Extraction  of  deciduous  teeth  is  indicated 
at  the  time  the  permanent  teeth  are  to  replace  them,  and  in 
advance  of  this  time  if  caries  has  attacked  them  to  such  an  extent 
that  they  are  beyond  treatment,  and  are  causing  such  a  disturb- 
ance that  the  general  health  of  the  child  is  being  hnpaired. 
Where  the  roots  of  the  teeth  remain,  acting  as  an  irritant,  or 
where  they  have  sharp  edges,  cutting  the  cheek,  liji,  or  tongue, 
they  should  be  extracted  or  rounded  off. 

Surgical  Cases.^ — Teeth  are  often  extracted  preceding  surgical 
operations  about  the  oral  cavity — viz.,  where  drainage  must  be 
established,  where  necrosis  involves  the  jaw  and  the  affected 
part  cannot  be  otherwise  treated,  and  in  those  cases  of  infection 
of  the  maxillary  sinus  where  drainage  cannot  be  otherwise  ob- 
tained. 

Traumatism. — Extraction  usuallj^  follows  in  a  case  of  fracture 
of  the  jaw  where  the  teeth  have  been  loosened  and  cannot  be  suc- 
cessfully retained  by  the  use  of  ligatures  or  appliances. 

Neuralgia. — It  is  frequentl^^  advisable  to  resort  to  extraction 
in  a  case  of  trifacial  neuralgia  where  a  tooth  is  the  etiologic 
factor  and  treatment  is  not  practicable. 

Infirmities. — In  cases  of  aged,  weak,  sick,  and  neurasthenic 
patients  who  cannot  very  well  withstand  the  treatment  that  is 
indicated  to  restore  an  affected  tooth  to  its  normal  function,  it 
may  be  better  to  resort  to  extraction  than  to  subject  them  to  the 
endurance  of  protracted  treatments. 


CONDITIONS  THAT  DO  NOT  INDICATE  EXTRACTION  73 


CONDITIONS   THAT   DO  NOT   INDICATE   EXTRACTION. 

An  operator,  before  deciding  to  remove  a  tooth,  should  care- 
fully consider  its  future  usefulness,  for  the  extraction  of  any 
tooth  whose  removal  is  not  made  necessary  by  local  or  systemic 
conditions  is  a  careless  destruction  of  tissue  and  a  sacrifice  of 
tooth  function.  The  demand  of  a  patient  that  a  tooth  be  re- 
moved should  not  be  considered  sufficient  cause  for  its  removal, 
as  the  patient  may  not  be  a  competent  judge  of  the  value  of  the 
particular  tooth,  and,  usually  not  being  versed  in  dental  proced- 
ure, cannot  correctly  diagnose  pathologic  conditions  that  require 
surgical  interference.  Often  a  slight  exposure  of  dentine,  due 
to  caries  or  even  to  recession  of  the  gum,  will  subject  the  patient 
to  considerable  pain,  and  cause  him  to  request  extraction  for  re- 
lief, when  the  simplest  sort  of  treatment  would  relieve  the  condi- 
tion. There  are  numerous  graver  lesions  of  the  teeth  and  sur- 
rounding tissues  that  often  cause  intense  suffering,  but  that  can 
be  reduced  and  the  function  restored  by  modern  dental  art. 

Unless  contraindicated  by  general  conditions  of  health  or  other 
circumstances,  an  operator  should  decline  to  remove  any  tooth 
that  is  of  any  value  or  can  be  made  of  any  value  to  its  possessor 
by  reasonable  treatment.  Among  other  circumstances  to  be 
noted,  the  following  conditions  should  be  carefully  considered 
before  extraction: 

Where  a  patient  has  lost  a  number  of  teeth  and  wishes  to  have 
some  extracted  that  are  affected,  but  that  are  in  good  alignment 
and  will  help  to  retain  an  artificial  denture,  they  should  not  be 
removed.  Requests  for  extraction  under  such  conditions  are 
often  made,  but  the  operator  should  be  the  judge  of  the  procedure 
to  be  followed,  and  especially  should  his  judgment  prevail  when 
the  affected  teeth  are  in  the  inferior  arch,  where  the  teeth  are 
often  the  only  means  of  retaining  an  artificial  denture. 

Often  a  patient  with  teeth  in  malocclusion  will  demand  that 
they  be  extracted  in  order  to  correct  this  disfigurement.  In  such 
case  every  endeavor  should  be  made  by  the  operator  to  correct 
the  condition,  either  doing  this  work  himself  or  referring  the  case 
to  a  competent  orthodontist. 

"When  a  patient  in  advanced  age  insists  on  extraction  of  teeth 
worn  down  by  abrasion,  but  that  are  firmly  supported  by  the  tis- 


74  INDICATIONS  AND  C0UNTERINDIGATI0N8 

sues,  the  operator  should  remember  that  it  is  often  preferable  to 
retain  such  teeth,  especially  when  other  teeth  about  the  mouth 
have  been  extracted  and  there  is  very  little,  if  any,  of  the  alveolar 
ridge  to  retain  an  artificial  denture. 

In  a  case  of  mesial  occlusion,  where  the  protrusion  is  marked, 
the  patient  often  becomes  discouraged  with  his  appearance  and 
seeks  the  extraction  of  the  teeth.  In  such  case  it  is  advisable  to 
explain  that,  while  an  artificial  denture  could  be  constructed,  the 
articulation  must  in  most  cases  follow  the  contour  of  the  natural 
teeth,  and  in  all  probability  a  practical  denture  to  correct  the 
object'ional  condition  could  not  be  made,  which  explanation  will 
generally  dissuade  a  patient  from  having  the  teeth  extracted. 

Many  other  conditions  similar  to  those  mentioned  may  be  pre- 
sented, and  the  operator  should  inform  the  patient  of  the  advan- 
tage of  retaining  teeth  wherever  it  is  at  all  possible  to  preserve 
them. 

COUNTERINDICATIONS  TO  OPERATING. 

Counterindications  to  operating  are  not  numerous,  and  are 
usually  presented  in  a  case  where  the  general  health  of  the 
patient  is  such  that  the  operation  would  be  performed  with  some 
degree  of  danger  to  the  patient's  life.  In  such  case  the  operator 
must  exercise  judgment  in  determining  the  situation,  as  he  must 
decide  whether  it  is  advisable  to  remove  the  offending  tooth,  or 
permit  it  to  remain  and  apply  some  palliative  treatment  until 
such  time  when  the  health  of  the  individual  has  been  restored 
sufficiently  to  allow  an  operation,  if  such  procedure  is  at  all 
possible. 

Impaired  health  is  often  occasioned  by  the  postponement  of  an 
operation,  the  patient,  dreading  the  thought  of  having  a  tooth 
extracted,  suffering  from  day  to  day  and,  in  addition,  losing 
much  sleep,  thereby  causing  the  system  to  become  gradually 
weaker.  In  such  case  the  appearance  of  the  patient  will  indicate 
the  necessary  precaution  that  must  be  observed  preceding  the 
operation.  Inquiry  should  be  made  as  to  the  length  of  time  the 
offending  tooth  has  been  a  means  of  disturbance  and  how  long  it 
has  affected  the  general  health.  Where  the  tooth  is  the  exciting 
cause  of  the  condition,  the  removal  of  the  cause  is  the  usual 
course  to  pursue,  and  the  severity  of  the  operation  then  naturally 
becomes  the  next  factor  to  be  considered.    If  the  operation  is 


COUNTERINDIGATIONS  TO  OPERATING  75 

one  that  is  difficult  and  requires  some  time  to  perform,  and  tlie 
patient  lacks  the  strength  to  endure  the  ordeal,  it  should  be 
postponed  and  treatment  conducted  in  concurrence  with  the 
advice  of  the  patient's  physician.  If,  however,  the  operation  is 
simple  and  can  be  quickly  performed,  it  is  usually  better  to 
relieve  the  condition  than  to  permit  the  tooth  to  remain,  with 
the  probability  of  increasing  the  involvement. 

Heart  Lesion. — Counterindication  to  extraction  may  be  pre- 
sented in  patients  who  have  organic  heart  lesions,  such  as  val- 
vular insufficiency,  hypertrophy,  and  fatty  degeneration.  An 
operation  may  result  in  a  fatal  shock  to  persons  so  afflicted, 
although  the  danger  of  such  a  termination  is  greatly  lessened  by 
the  use  of  a  general  anesthetic.  Where  the  case  is  of  such  a 
nature  that  the  operation  may  endanger  the  life  of  the  patient, 
restoratives  should  always  be  in  readiness,  and  it  is  advisable  to 
have  the  patient's  physician  in  consultation  and  at  the  operation. 

Abscessed  Teeth. — A  tooth  that  is  the  cause  of  alveolar  abscess, 
with  extensive  infiltration  of  the  surrounding  tissues  and  exces- 
sive swelling,  is  often  classified  as  a  counterindication;  but,  as 
the  tooth  is  the  exciting  cause  of  the  condition,  its  removal  will 
lessen  the  probability  of  endangering  the  structure  beyond  the 
area  already  involved,  and  facilitate  the  treatment  of  the  infec- 
tion.    (See  treatment  for  acute  septic  pericementitis,  ]5age  361.) 

Acute  alveolar  abscess  can  be  classed  as  a  counterindication 
only  when  the  physical  condition  of  the  patient  will  not  allow 
extraction.  The  tissues  surrounding  the  tooth  are  usually  pain- 
ful to  the  touch,  and  fear  on  the  part  of  the  operator  of  inflicting 
pain  is  undoubtedly  the  reason  so  many  teeth  that  are  involved 
in  an  acute  septic  disturbance  are  not  immediately  extracted  and 
the  operation  is  postponed  until  the  case  reaches  a  stage  where 
extraction  is  imperative.  There  is  a  too  common  belief  that  an 
abscessed  tooth  should  not  be  extracted  until  a  free  evacuation 
of  pus  can  be  had  by  lancing.  This  belief,  carried  into  practice, 
usually  prolongs  the  suffering,  and  sometimes  permits  the  local 
infection  to  become  systemic. 

Temporary  Ankylosis. — Often  temporary  ankylosis  is  classi- 
fied as  a  counterindication  on  account  of  the  inability  of  the 
patient  to  open  the  mouth  and  the  painful  procedure  necessary 
to  open  it.  This  condition  is  more  readily  overcome  by  admin- 
istering a  general  anesthetic  and  extracting  the  tooth,  if  it  is  the 


76  INDICATIONS  AND  C0UNTERINDICATI0N8 

exciting  cause  of  the  condition,  than  by  permitting  it  to  remain. 
Coiinterindications  occur  only  where  the  vitality  of  the  patient 
is  lowered  to  such  an  extent  as  to  render  him  unable  to  undergo 
the  operation,  in  which  case  the  tooth  should  be  extracted  as 
soon  as  his  health  has  been  sufficiently  regained  to  permit 
operating. 

Hemorrhagic  Diathesis. — With  a  hemophilic  patient,  where 
there  is  a  possibility  of  a  fatal  case  of  hemorrhage  following  the 
operation,  extraction  is  counterindicated.  If  palliative  treat- 
ment can  be  applied  and  the  operation  avoided,  it  should  be 
done;  but,  should  this  procedure  be  of  no  avail,  and  retention  of 
the  tooth  would  endanger  the  life  of  the  patient  as  much  as  an 
operation,  the  operation  should  be  performed.  Where  possible, 
there  should  be  preliminary  treatment  preceding  the  operation. 
(See  treatment  for  hemophilia,  page  376.) 

Pregnancy. — In  all  cases  of  pregnancy  the  operation  should  be 
postponed  if  possible;  but,  where  the  patient  has  had  a  number 
of  sleepless  nights,  all  palliative  treatments  failing  to  give  relief, 
rather  than  have  her  subjected  to  any  further  suffering,  a  general 
anesthetic  should  be  administered  and  the  operation  performed 
in  the  presence  of  the  family  physician. 

Epilepsy. — ^Epileptics  are  unsatisfactory  patients,  as  the  shock 
of  an  operation  may  bring  on  an  attack.  If  imperative,  extrac- 
tion can  be  performed,  but  the  patient  must  receive  constant 
attention  to  prevent  him  from  injuring  himself  or  others  in  case 
of  an  attack.  Should  an  attack  follow,  the  patient  should  be 
laid  in  a  comfortable  position,  allowing  plenty  of  air,  and  re- 
covery will  usually  be  rapid. 


CHAPTER  VI. 
EXAMINATION  OF  THE  MOUTH  AND  TEETH. 

An  examination  of  tlie  mouth  and  the  teeth  to  he  extracted 
necessarily  precedes  every  operation,  and  should  he  carefully 
conducted.  A  detailed  survey  of  the  entire  situation  must  be 
made,  as  on  the  resulting-  conclusion  may  depend  the  success  of 
the  operation.  A  superficial  mspection  of  the  parts,  with  a 
hasty  diagnosis,  is  liable  to  prove  disastrous. 

The  operator  should  not  depend  solely  on  the  word  of  the 
patient  as  to  the  identity  of  the  atfected  tooth,  but  must  bear 
in  mind  that  irritation  along  a  nerve  trunk  may  produce  a  sensa- 
tion of  pain  in  any  of  its  termini,  and  that  any  inflammatory  or 
congested  condition  of  one  tooth  frequently  causes  pain  in  an- 
other, even  when  the  affected  tooth  has  not  seriously  annoyed 
the  patient.  The  majority  of  examinations  can  be  made  by 
inspection,  manipulation,  and  instrumentation.  The  instru- 
ments required  consist  of  mouth  mirror,  foil  carrier,  explorer, 
and  probe  (pages  54,  55),  and  should  always  be  kept  sterilized 
and  in  readiness.  They  are  used  in  the  same  manner  as  for  the 
examination  preceding  other  operations  about  the  teeth,  the 
mirror  and  explorer  being  used  first  and  the  other  instruments 
employed  as  the  case  may  demand.  When  as  thorough  an  ex- 
amination as  can  be  made  with  these  instruments  fails  to  reveal 
sufficient  information  for  a  correct  diagnosis,  a  radiograph  of 
the  part  will  usually  outline  the  existing  condition. 

ATTITUDE  OF  THE  OPERATOR  WHEN  MAKING  AN 
EXAMINATION. 

During  the  examination  the  operator  should  use  every  tactful 
effort  to  establish  and  maintain  the  confidence  of  the  patient, 
as  such  relation  of  confidence  is  an  important  factor  in  a  suc- 
cessful operation.  Q'he  operator's  perfect  self-reliance  on  his 
ability  subconsciously  produces  a  reciprocal  feeling  on  the  part 
of  the  patient,  inducing  him  to  more  readily  comply  with  any 

77 


78  EXAMINATION  OF  MOUTH  AND  TEETH 

instruction  relative  to  position  or  conduct  previous  to  and  dur- 
ing the  operation.  The  operator,  by  his  self-reliant  conduct, 
allays  any  fear  or  excitement  his  patient  may  manifest,  while 
any  uneasiness,  hesitation,  or  awkwardness  on  the  part  of  the 
operator  may  cause  interference  and  will  increase  the  natural 
dread  of  the  patient,  frequently  rendering  a  patient  hysterical 
who  would  otherwise  be  composed  and  tractable.  The  operator 
should  refrain  from  stating  his  opinion  of  the  pending  operation 
unless  he  expects  to  encounter  difficulties  or  realizes  the  proba- 
bility of  an  unavoidable  fracture  of  the  tooth.  Forecasting  the 
result  of  an  operation  should  be  avoided,  as  the  outcome  can- 
not always  be  definitely  determined.  Extensive  caries  or  abnor- 
malities of  the  roots  of  a  tooth  may  cause  unexpected  resistance 
or  fracture  in  •  contraindication  of  bis  prognostication,  which 
would  not  leave  a  favorable  impression  on  the  patient.  The 
operator  must  gauge  the  intelligence  of  the  patient,  and  impart 
such  infonnation  as  may  be  necessary  in  phraseology  suited  to 
the  comprehension  of  the  individual. 

EXAMINING  THE  MOUTH. 

The  examination  of  the  mouth  is  made  with  the  patient  and 
operator  in  position  similar  to  that  occupied  when  operating 
(Chapter  VII).  When  introducing  the  instruments  and  fingers 
into  the  oral  cavity,  care  should  be  taken  not  to  impinge  on  the 
lips,  especially  if  they  are  fissured,  or  if  the  patient,  in  applying 
some  home  remedy  to  the  affected  tooth,  has  allowed  some  of  it 
to  come  in  contact  with  the  lips,  rendering  them  more  sensitive. 
Any  inflammatory  condition  of  the  mucocutaneous  surface  some- 
times makes  the  parts  highly  painful  to  the  touch,  and  they 
should  not  be  disturbed  any  more  than  is  absolutely  necessary. 
The  operator  should  observe  the  size  of  the  oral  cavity  and  the 
location  of  the  affected  tooth,  and  calculate  to  what  extent  the 
mouth  should  be  opened  during  the  operation  in  order  to  keep 
the  involved  tooth  continually  in  view.  The  cheek  muscles  and 
tongue  are  considered,  noting  to  what  extent  they  interfere  with 
the  examination,  as  the  same  degree  of  interference  will  be 
experienced  during  the  operation,  and  some  method  must  be 
adopted  to  overcome  it.  In  the  case  of  a  mouth  that  contains 
only  a  few  scattered  teeth,  special  observation  of  the  lips,  cheeks, 
and  tongue  is  made,  as  they  very  often  interfere  with  the  appli- 


SURGICAL  DISEASES  ABOUT  THE  MOUTH  79 

cation  of  the  instruments.  The  necessity  of  supporting  the  man- 
dible must  also  be  considered,  and  the  best  method  in  which 
this  can  be  done  is  determined.  When  a  general  anesthetic  is 
to  be  administered,  the  insertion  of  a  mouth-prop,  together  with 
its  size  and  position  in  the  mouth,  must  be  taken  into  account. 

REMOVING  FOREIGN  BODIES  PRECEDING  EXAMI- 
NATION AND  OPERATION. 

All  artificial  plates,  loose  crowns,  and  bridges  should  be  re- 
moved before  completing  an  examination.  No  attempt  to  oper- 
ate should  be  made  with  these  foreign  bodies  in  the  mouth, 
especially  if  the  patient  is  to  receive  a  general  anesthetic.  Any 
orthodontia  appliance  that  may  be  in  place  and  would  be  dis- 
turbed during  the  operation  should  be  removed  to  prevent  inter- 
ference. Any  cotton,  gauze,  or  gutta-percha  dressings  that  may 
be  in  the  tooth  to  be  operated  on  should  also  be  removed,  for, 
should  the  tooth  fracture  during  the  operation,  these  dressings 
may  interfere  with  a  reapplication  of  the  instruments.  Such 
dressings  are  not  only  a  hindrance  to  the  operator,  but  are  also 
liable  to  drop  on  the  tongue  or  pass  down  the  throat,  causing 
annoyance  to  the  patient. 

SURGICAL  DISEASES  ABOUT  THE  MOUTH. 

Any  surgical  disease  about  the  mouth  or  associated  with  the 
involved  tooth  must  be  taken  into  account  during  the  examina- 
tion. Alveolar  abscess  is  the  most  common  lesion,  and,  if 
present,  the  extent  of  its  attack  on  the  tissues  is  observed — 
whether  a  sinus  is  established  and  what  other  parts  are  affected 
by  it  are  noted — the  operator  determining  at  the  same  time  the 
treatment  that  may  be  required  before  and,  in  a  measure,  imme- 
diately after  the  extraction.  Temporary  ankylosis  is  often 
established  in  connection  with  this  abscessed  condition,  the 
mouth  being  partially  or  completely  closed.  In  such  case  it  is 
noted  whether  the  mouth  can  be  opened  sufficiently  to  extract 
the  affected  tooth,  or  whether  it  will  be  necessary  to  use  the 
wooden  wedge  or  mouth-gag  to  secure  access  to  the  field  of 
operation. 

As  the  maxillary  sinus  is  occasionally  involved  when  a  tooth 
located  in  close  apposition  to  it  is  diseased,  the  affected  tooth 


80  EXAMINATION  OF  MOUTH  AND  TEETH 

and  its  associated  tissues  should  be  carefully  inspected  to  de- 
termine whether  the  floor  of  the  antrum  is  involved  or  is  liable 
to  be  disturbed  during  the  extraction. 

Necrosis  is  a  condition  that  is  occasionally  presented.  The 
lower  jaw  is  the  one  usually  affected,  and,  when  such  condition 
prevails,  its  cause  should  be  ascertained  and  the  nature  of  the 
attack  determined,  whether  confined  to  the  alveolar  process  or 
affecting  a  greater  area.  The  extent  of  the  involvement  should 
be  established  in  order  that  the  necessary  treatment  may  be 
considered,  and  the  proper  surgical  interference  outlined  in  ad- 
vance of  the  extraction. 

If  a  previous  fracture  of  the  jaw  has  occurred,  the  patient  will 
usually  give  its  liistor}^,  and,  if  of  recent  occurrence,  special  care 
must  be  taken  not  to  subject  the  weakened  mandible  to  greater 
force  than  it  can  withstand.  Care  should  be  observed  also 
where  a  dislocation  has  occurred,  and  the  liability  of  a  recur- 
rence of  the  dislocation  be  borne  in  mind. 

The  glands,  when  involved,  nmst  be  examined,  and  the  extent 
of  the  involvement  carefully  noted.  Any  foreign  growths  about 
the  mouth  should  also  be  considered. 

EXAMINING  THE  TOOTH,  ADJACENT  TEETH,  AND 

TISSUES. 

Before  proceeding  to  the  examination  of  the  tooth  to  be  ex- 
tracted, the  involved  tooth  and  the  tissues  surrounding  it  are 
thoroughly  syringed  with  an  antiseptic  solution  to  clear  away 
any  debris  that  may  have  accumulated.  AVith  absorbent  cotton, 
in  the  form  of  a  pellet  and  held  in  the  foil  carrier,  all  saliva  that 
may  interfere  with  the  examination  is  wiped  away.  If  the  flow 
of  saliva  is  too  free,  a  large  piece  of  cotton  is  placed  on  the 
buccal  and  lingual  sides  of  the  tooth  to  keep  the  field  open  for 
examination.  In  a  pus  case  the  same  method  may  be  employed, 
but  pressure  on  the  gum  should  be  avoided,  as  it  will  produce 
pain  and  likely  cause  the  pus  to  cover  the  affected  tooth.  Pres- 
sure should  be  avoided  also  when  blood  is  oozing  from  the  mar- 
gin of  the  gum  tissue. 

When  the  j^eridental  membrane  of  the  tooth  is  in  an  inflamma- 
tory condition,  the  instrument  used  for  examination  should  not 
be  pressed  on  the  tooth,  as  the  resulting  pain  may  be  so  intense 
as  to  throw  the  patient  into  a  highly  nervous  state,  and  possibly 


EXAMINIXG  TOOTH  AND   TISSUES  81 

cause  the  operation  to  be  postponed.  The  same  precaution 
should  also  be  observed  in  touching  sensitive  parts  of  a  tooth 
or  root  with  an  inflamed  pulp. 

Examining  a  Tooth  Free  of  Caries. — The  alignment  of  the 
tooth  is  observed,  especially  noting  whether  it  inclines  from  the 
normal,  and  whether  it  is  isolated  or  has  teeth  adjacent  to  it. 
The  firmness  of  its  attachment  to  the  supporting  tissues  is  in- 
vestigated to  determine  the  amount  of  force  that  may  be  required 
to  detach  it.  The  degree  of  its  firmness  is  determined  by  placing 
the  thumb  and  index  finger  on  the  sides  of  the  tooth,  or  by 
adjusting  Derenberg  tweezers  to  each  side  of  the  crown,  or  by 
applying  the  probe  or  an  exploring  instrument  to  the  occlusal 
sui'face,  and  swaying  the  tooth  from  side  to  side. 

The  shape  and  size  of  the  crown  and  neck  of  the  tooth  are 
examined  in  order  that  forceps  with  beaks  that  most  nearly  con- 
form to  the  shape  of  the  neck,  and  that  will  grasp  as  much  as 
possible  of  the  tooth,  may  be  selected.  At  the  same  time  the 
advisability  of  making  an  adjustment  to  the  root  of  the  tooth  or 
only  to  the  neck  is  determined,  which  conclusion  is  governed  by 
the  strength  of  its  attachment  to  the  supporting  tissues  and  the 
condition  of  the  crown. 

The  necessity  of  loosening  the  tooth  with  an  elevator  preceding 
an  application  of  the  forceps  should  also  be  determined.  When 
the  approximating  tooth  is  to  be  used  as  a  fulcrum,  its  support 
is  considered,  as  lack  of  attention  to  this  detail  may  result  in  the 
loosening  of  the  attachment  of  the  tooth  thus  utilized. 

Examining  a  Tooth  with  a  Fractured  Crown. — When  examin- 
ing a  tooth  with  a  fractured  crown  caused  by  defective  filling 
or  in  some  other  manner,  all  the  parts  should  l)e  thoroughly 
examined.  As  a  rule,  one  part  of  the  crown  remains  adherent 
to  the  tooth,  while  the  other  part  is  loose;  or  both  parts  may  be 
separated  from  the  roots  of  the  tooth  and  held  by  the  gum  tissue 
only.  In  case  one  part  is  firmly  adherent,  an  examination  will 
determine  whether  it  is  necessary  to  remove  the  broken  fragment 
before  applying  the  instrument  to  the  part  attached.  In  a  great 
many  cases  the  fragment  is  permitted  to  remain,  as  it  seldom 
interferes  with  the  operation.  If,  however,  it  interferes,  it 
must  be  disposed  of  before  the  removal  of  the  firmer  part.  If 
both  pieces  are  severed,  the  necessity  of  removing  them  before 
the  remainder  of  the  tooth  is  extracted  should  be  considered. 


82  EXAMINATION  OF  MOUTH  AND  TEETH 

Examining  a  Tooth  with  Checked  Enamel. — When  the  enamel 
of  the  crown  of  a  tooth  to  be  extracted  is  checked,  the  checked 
line  should  be  followed  AYitli  a  fine  exjjlorer,  in  the  same  manner 
as  if  the  tooth  were  to  be  filled,  to  determine  whether  the  crown 
has  been  weakened,  for,  if  there  is  a  weakening  of  the  crown 
and  the  parts  are  no  longer  firmly  cemented,  in  which  case  a 
probable  fracture  may  be  suspected,  the  crown  is  not  to  be  de- 
pended on  to  sujiport  the  instrument. 

Examining  a  Tooth  Attacked  by  Caries. — Where  the  crown  of 
a  tooth  has  been  attacked  by  caries,  the  amount  of  destruction 
and  location  of  the  cavity  should  be  noted,  as  these  conditions 
largely  govern  the  technic  of  the  extraction  of  the  tooth.  Where 
an  extensive  amount  of  caries  exists  on  the  occlusal  surface,  and 
the  outer  walls  are  intact,  the  operator  should  not  be  hasty  in 
applying  forceps,  but  should  first  examine  the  strength  of  the 
walls  with  Derenberg  tweezers.  It  is  frequent  for  the  walls  not 
to  be  as  strong  as  they  appear,  and  the  application  of  the  forceps 
will  crush  them,  leaving  the  root  in  situ.  Such  an  occurrence 
can  be  avoided  by  careful  examination,  for,  when  a  condition  of 
this  character  exists,  the  procedure  should  be  as  if  only  roots 
were  to  be  extracted. 

Where  the  caries  is  on  the  labial,  buccal,  or  lingual  surface, 
the  extent  of  the  involvement  should  be  estimated.  If  it  extends 
below  the  gum  margin,  the  probe  will  generally  reveal  the 
amount  of  decay,  and  acquaint  the  operator  with  the  depth  to 
which  he  must  apply  the  beaks  of  the  forceps  to  obtain  a  hold 
that  is  sufficiently  secure  to  deliver  the  tooth.  Where  the  cavity 
is  on  the  mesial  or  distal  surface  (commonly  termed  a  proximal 
cavity),  its  extent  should  be  especially  noted  in  order  that  a 
detailed  outline  of  the  operation  be  formed. 

Each  part  of  a  compound  cavity  should  be  examined  sepa- 
rately and  then  considered  collectively,  as  this  dual  condition 
usually  increases  the  complication.  There  are  cases,  however, 
where  the  location  of  a  cavity  is  such  that  a  thorough  examina- 
tion is  made  with  difficulty.  Apparently  the  remaining  part  of 
the  tooth  is  strong,  but  decay  may  have  undermined  the  crown 
to  such  an  extent  that  it  would  fracture  under  the  stress  of  the 
extraction  movements.  In  these  cases  every  means  should  be 
employed  to  obtain  as  complete  information  of  the  amount  of 
caries  as  is  possible.     Where  caries  has  extended  to  the  pulp 


EXAMINING  TOOTH  AND  TISSUES  83 

chamber,  the  extent  of  its  involvement  is  noted,  and,  where  it 
has  extended  beyond  the  pulp  chamber,  the  root  canals  should 
also  be  examined  to  determine  how  far  it  has  spread.  The 
firmness  of  the  tooth's  attachment  should  be  tested  in  the  same 
manner  as  if  the  crown  were  intact.  The  strongest  and  weakest 
points  of  the  remaining  part  of  the  crown,  its  relative  strength, 
and  whether  it  is  more  favorable  to  the  application  of  the  for- 
ceps than  the  elevator,  should  be  decided  before  removal  is 
attempted. 

When  forceps  are  indicated,  the  possibility  of  their  retention 
when  the  tooth  is  grasped  by  them,  and  whether  the  tooth  will 
bear  the  strain  necessary  for  its  deliverance,  are  the  important 
matters  to  be  considered,  and,  where  an  elevator  is  indicated, 
the  most  favorable  part  of  the  tooth  to  which  it  can  be  applied 
is  determined. 

Examining'  the  Root  of  a  Tooth. — AYlien  a  root  is  all  that  re- 
mains of  a  tooth,  its  location  and  relation  to  a  normal  position 
should  be  noted,  and  whether  it  is  a  part  of  a  fractured  tooth 
or  the  result  of  caries  having  destroyed  the  crown  should  be 
determined.  The  approximate  size  of  the  root  can  usually  be 
gauged  by  its  ex230sed  surface,  and  is  done  by  making  a  com- 
parison of  the  circumference  of  that  surface  with  the  corre- 
sponding circumference  of  the  root  of  the  normal  tooth.  An 
inspection  of  the  corresponding  tooth  on  the  opposite  side,  if 
present,  will  greath"  aid  in  forming  an  idea  of  the  dimensions 
of  the  root  under  consideration.  When  there  is  more  than  one 
root,  the  operator  should  learn  whether  the  roots  are  firmly 
united  to  each  other  or  separated.  If  there  is  a  separation,  the 
relation  of  one  root  to  the  other  and  the  possibility  of  applying 
an  instrument  between  the  roots  for  their  removal  should  be 
determined,  and,  where  the  roots  are  united,  it  is  determined 
whether  they  should  be  extracted  intact  or  separately.  Where 
a  root  is  affected  by  caries,  the  extent  of  decay  and  how  far  the 
root  canal  may  be  involved  is  ascertained  by  probing.  The 
weakest  and  strongest  parts  of  the  root  are  then  ascertained 
to  determine  whether  the  forceps  or  an  elevator  shall  be  used, 
and  to  indicate  where  the  instrument  selected  can  be  best  ap- 
plied. The  probable  amount  of  resistance  that  may  be  encoun- 
tered in  its  removal  is  estimated  in  the  same  manner  as  if  the 
crown  were  intact  (page  81). 


84  EXAMINATION  OF  MOUTH  AND  TEETH 

Examining  a  Root  Overlaid  with  Gum  Tissue. — An  inflamed 
area,  a  loose  flap  of  gum  tissue,  a  congestion  of  the  soft  tissues, 
or  small,  sharp,  protruding  edges  of  tooth  structure,  will  usually 
indicate  the  location  of  the  root  of  a  tooth  that  is  overlaid  with 
the  gum  tissue.  Frequently  an  external  examination  may  be 
made  by  carefully  inserting  a  probe  or  explorer  underneath  the 
gum  tissue  folds,  but  care  should  be  taken  to  avoid  a  possible 
hemorrhage,  which  would  interfere  with  a  further  examination. 
Where  possible,  an  instrument  is  inserted  into  the  root  canal  or 
applied  to  the  edge  of  the  root  to  ascertain  the  firmness  of  its 
attachment.  One  must  not  always  depend  on  finding  the  root 
in  its  normal  location.  The  author  recalls  examining  an  inferior 
first  molar  where  the  distal  root  of  the  tooth  was  lying  on  the 
buccal  surface  of  the  roots  of  the  second  molar.  The  history  of 
the  case  indicated  that  the  first  molar  had  been  operated  on,  the 
parts  being  abscessed,  and  that  the  former  operator,  after 
searching  for  the  root  a  long  time  without  success,  informed  the 
patient  that  ''nature  would  throw  it  off."  In  this  case  he  un- 
doubtedly pressed  the  root  of  the  tooth  into  the  abscess  cavity, 
which  extended  toward  the  second  molar. 

Examining  a  Filled  Tooth. — A  tooth  that  is  filled  with  amal- 
gam, cement,  or  gold  should  be  closely  examined,  and  notation 
made  of  the  size  and  strength  of  the  filling  and  the  probability 
of  the  filling  supporting  the  crown  or  surface  of  the  tooth  to 
which  the  instrument  is  to  be  applied  during  the  extraction. 
Before  the  operation  is  begun,  the  operator  should  determine 
whether  to  remove  a  filling  where  extensive  caries  exists,  or  to 
permit  it  to  remain,  in  the  latter  case  depending  on  the  filling 
to  withstand  the  pressure  of  the  beaks  of  the  forceps  or  other 
instruments. 

Examining  a  Root  Supporting  a  Shell  Crown. — When  a  shell 
crown  is  attached  to  a  tooth  to  be  extracted,  a  careful  exami- 
nation should  be  made  to  determine  whether  the  crown  is  se- 
curely cemented  to  the  tooth,  and,  as  with  a  tooth  that  is  filled, 
the  propriety  of  removing  the  crown  or  permitting  it  to  remain 
should  be  considered.  A  close  examination  of  the  neck  of  the 
tooth  for  probable  decay  and  to  ascertain  the  fit  of  the  crown  at 
this  point  is  also  necessary,  in  order  to  determine  whether  the 
artificial  crown  may  be  depended  on  to  support  the  remainder 
of  the  tooth  and  carr}^  it  from  its  socket  when  the  forceps  are 


EXAMINING  TOOTH  AND  TISSUES  85 

ap])lied  to  it  for  its  extraction.  If  it  is  decided  to  permit  the 
crown  to  remain,  the  firmness  of  the  attachment  of  the  roots  to 
the  tissues  should  be  noted  in  the  same  manner  as  if  the  tooth 
possessed  a  natural  crown. 

Examining  a  Root  Supporting  a  Dowel  Crown. — A  tooth  with 
a  dowel  crown,  with  or  without  a  l)aud,  should  be  subjected  to 
the  same  kind  of  examination  as  a  tooth  with  a  shell  crown. 
The  examination  should  be  made  with  special  reference  to  the 
manner  of  applying  the  beaks  of  the  forceps  so  as  to  avoid  any 
fracture  of  the  artificial  crown  during  the  extraction.  The  oper- 
ator should  determine  whether  to  depend  on  the  crown  to  sup- 
port the  beaks  of  the  forceps,  or  to  operate  independently  of  the 
crown  and  apply  the  forceps  to  the  root  above  the  crown. 

Examining  a  Bridge  Abutment. — AVhen  a  piece  of  bridgework 
and  the  root  which  serves  as  its  abutment  must  be  removed,  the 
operator  should  note  the  strength  of  the  attachment  of  the  root 
of  the  tooth  to  the  tissue  to  determine  whether  he  can  remove  the 
bridge  and  its  abutment  intact,  or  whether  it  will  be  necessary  to 
first  remove  the  bridge  and  then  extract  the  tooth. 

Examining  a  Treated  Tooth. — A  tooth  that  has  been  treated 
by  another  operator  should  be  very  carefully  examined,  and  spe- 
cial inquiry  be  instituted  to  ascertain  if  an  attempt  has  been 
made  to  devitalize  the  pulp.  Arsenical  necrosis  has  resulted 
from  such  treatment  after  extraction  where  the  operator,  not  be- 
ing aware  of  the  presence  of  an  arsenious  compound  in  the  tooth, 
proceeded  with  the  operation  without  realizing  the  probable  seri- 
ous consequences.  If  the  tooth  fractures  during  the  operation 
and  any  of  the  arsenic  remains  about  the  socket,  the  gum  tissues 
would  in  all  probability,  in  a  few  days  after  the  extraction,  be 
found  in  a  gangrenous  state  and  the  alveolus  necrotic. 

Examining  the  Adjacent  Teeth  and  Approximating  Space. — 
The  teeth  adjacent  to  the  one  to  be  extracted  should  be  examined 
to  determine  whether  either  will  interfere  with  the  free  applica- 
tion of  the  forceps  or  the  elevator,  and  prevent  an  unobstructed 
completion  of  the  extraction  movements  and  delivery  of  the  tooth 
from  the  socket,  bearing  in  mind  that  the  tooth  to  be  removed 
may  have  divergent  roots,  and  not  forgetting  to  calculate  whether 
the  exit  can  be  made  through  the  existing  space  or  must  be  made 
laterally.  This  should  receive  special  attention  where  the  in- 
volved tooth  is  in  malposition,  or  where  the  crown  has  com- 


86  EXAMINATION  OF  MOUTH  AND  TEETH 

pletely  decayed  away  and  only  the  root  remains.  Where  the 
adjacent  teeth  impinge  on  the  defective  tooth,  the  operator 
should  ascertain  the  amount  of  interference,  and  determine 
whether  a  sufficient  amount  of  structure  can  be  removed  from 
the  tooth  to  be  extracted  to  allow  an  unobstructed  delivery. 

The  advisability  of  using  an  approximating  tooth  as  a  fulcrum 
in  a  case  where  it  is  deemed  necessary  to  apply  an  elevator  is 
considered,  and  by  a  proper  test  it  is  determined  whether  the 
selected  tooth  possesses  sufficient  stability  to  bear  the  strain  of 
applying  the  instrument  indicated  in  that  particular  case  to  dis- 
lodge the  affected  tooth.  If  the  tooth  to  be  used  as  a  fulcrum  is 
filled  or  crowned,  the  operator  should  determine  whether  the  arti- 
ficial structure  will  be  disturbed  by  using  the  tooth  for  that  pur- 
pose during  the  extraction.  Care  should  be  exercised  not  to  in- 
trude on  adjacent  teeth  where  they  contain  large  fillings,  or 
where  they  are  decayed  or  being  treated. 

Examining  the  Gums. — The  gum  tissue  should  be  examined, 
noting  to  what  extent  it  surrounds  the  affected  tooth,  or  whether 
there  is  any  recession  of  it  from  the  neck  of  the  tooth.  The  ex- 
amination should  determine  how  firmly  the  tissue  adheres  to  the 
tooth,  the  feasibility  of  applying  the  elevator  or  beaks  of  the  for- 
ceps under  its  margin,  or  the  necessity  of  lancing  it  from  about 
the  tooth. 

The  operator  should  endeavor  to  save  as  much  as  possible  of 
the  normal  gum  tissue,  examining  the  parts  with  a  view  to  avoid 
lacerating  it  during  the  operation.  A  loose  tooth  is  often  held  in 
position  by  this  tissue  alone,  and  it  is  more  liable  to  be  torn  away 
during  extraction  than  the  gum  surrounding  a  normally  attached 
tooth.  When  operating  on  an  impacted  tooth  where  the  gum 
tissue  partially  overlies  the  crown,  special  note  should  be  made 
of  the  amount  of  adhesion  of  the  gum  tissue,  as  there  is  a  tend- 
ency to  firm  adhesion  in  such  case.  Where  the  alveolar  process 
is  liable  to  be  exposed,  it  is  essential  that  as  much  as  possible  of 
the  normal  tissue  be  retained  for  its  protection.  Especially 
should  the  gum  tissue  be  retained  where  a  number  of  contiguous 
teeth  are  extracted,  for  in  such  case  it  is  of  paramount  impor- 
tance to  preserve  the  tissue  for  the  protection  of  the  alveolus 
after  the  operation. 

Examining  the  Alveolar  Process. — The  examination  must  de- 
termine whether  the  alveolar  process  is  in  a  normal  or  an  ab- 


USE  OF  RADIOGRAPH  IN  EXAMINATION  87 

normal  state,  and  furnish  reasonable  knowledge  of  its  density, 
elasticity,  and  the  probability  of  it  being  dilated  or  fractured  dur- 
ing an  extraction.  By  passing  the  thumb  and  index  finger  over 
the  gum  tissue  covering  the  alveolus  a  fair  idea  of  the  strength  of 
the  tissue  may  be  formed.  The  strongest  and  weakest  points  of 
the  process  surrounding  the  tooth  should  be  noted,  and  a  conclu- 
sion reached  whether  its  relation  to  the  particular  tooth  will  per- 
mit the  free  application  of  the  beaks  of  the  forceps  or  the  blade 
of  the  elevator.  Where  the  alveolar  process  is  unusually  heavy, 
the  operator  determines  whether  extraction  is  liable  to  cause  a 
fracture  of  the  tooth  or  the  alveolus,  and  outlines  his  operation  to 
avoid  these  accidents.  When  it  becomes  necessary  to  make  an 
alveolar  application,  consideration  should  be  given  to  the  extent 
to  which  such  an  application  can  be  safely  made.  When  the  mar- 
gin of  the  alveolar  process  is  carious,  the  extent  of  the  involve- 
ment is  partially  revealed  by  observing  the  inflammation  coexist- 
ing in  the  gum  tissue.  If  the  process  has  been  weakened,  the 
amount  of  destruction  that  has  taken  place  should  be  ascertained, 
and  at  the  same  time  it  should  be  learned  whether  the  parts  are 
broken  down  sufficiently  to  permit  an  easy  delivery  of  the  tooth. 
The  advisability  of  removing  the  defective  alveolus  at  the  same 
time  the  tooth  is  extracted  should  be  considered.  The  alveolar 
process,  from  the  standpoint  of  the  exodontist,  is  always  a  very 
important  structure,  and  not  to  give  it  adequate  consideration 
will  often  result  in  a  failure  to  extract  the  tooth  in  its  entirety. 

USE  OF  THE  RADIOGRAPH  IN  EXAMINATION. 

If  the  examinations  mentioned  do  not  convey  to  the  operator 
sufficient  information  concerning  the  tooth  to  be  extracted,  he 
should  resort  to  the  use  of  the  radiograph  to  outline  a  definite 
plan  of  procedure.  Since  the  introduction  of  the  radiograph  into 
dentistry,  and  more  especially  for  its  use  in  connection  with  the 
operation  of  extraction,  it  has  become  indispensable  for  the  pur- 
pose of  securing  a  correct  diagnosis  of  a  tooth  that  is  beyond  the 
view  of  the  eye  or  the  reach  of  instruments. 

The  radiograph  has  made  obsolete  those  explorative  examina- 
tions that  require  considerable  lancing  of  the  gum  tissue  and 
the  cutting  away  of  the  alveolar  process  to  diagnose  the  con- 
dition, which,  even  with  all   this  lancing  and  destruction  of 


88  EXAMI^^ATION  OF  MOUTH  AND  TEETH 

tissue,  give  no  definite  knowledge  of  the  anatomical  relation  of 
the  tooth  to  the  alveohir  strncture  or  to  the  adjacent  teeth,  or  of 
the  conformation  of  its  roots.  The  outcome  of  an  operation 
based  on  a  diagnosis  made  by  this  explorative  method  has 
always  been  very  uncertain,  notwithstanding  the  skill  that  may 
have  l)een  possessed  ])y  the  operator  and  the  pains  taken  by  him 
to  perform  a  successful  operation. 

With  the  aid  of  a  radiograph  the  operator  has  the  advantage 
of  forming  a  positive  diagnosis  of  the  condition  of  the  involved 
tooth,  for  by  interpreting  the  picture  he  can  outline  the  required 
operative  procedure  in  advance  of  the  operation,  enabling  him 
to  eliminate  all  unnecessary  loss  of  time  in  operating  and  con- 
serve the  greatest  possible  amount  of  tissue  by  the  operation. 

Obtaining  a  radiograph  of  a  tooth  is  a  comparatively  simple 
matter  for  the  patient.  Radiographs  are  obtained  in  two  ways, 
and  are  termed  intraoral  and  extraoral. 

Intraoral  Radiograph. — The  intraoral  radiograph  is  obtained 
by  using  an  ordinary  photograph  film,  cut  into  suita1)le  size  to 
cover  the  area  to  be  brought  into  view.  The  film  is  securely 
wrapped  in  double  thickness  of  black  paper,  so  as  to  exclude  all 
daylight,  and  this  in  turn  is  protected  by  rubber  tissue,  similar 
to  that  employed  by  surgeons  when  using  a  moist  application. 
The  film,  so  protected,  is  placed  in  the  patient's  mouth  adjacent 
to  the  parts  to  be  radiographed,  and  held  firmly  in  place  with 
the  hand,  or  with  one  of  a  number  of  devices  in  use  to  avoid 
exposing  the  hand  to  the  x-rays.  The  exposure  is  from  two  to 
ten  seconds,  and  is  so  short  that  the  liability  of  a  patient  being 
burned  by  these  rays  is  practically  nil.  Frequently  a  i^atient 
objects  to  the  use  of  the  radiograph  on  account  of  fear  of  the 
rays,  but,  if  it  is  explained  to  him  that  the  exposure  is  very 
short,  and  that  a  special  device  is  used  to  protect  him  from  any 
possible  injury,  his  mind  is  readil}^  placed  at  ease.  Wherever 
possible,  the  intraoral  method  should  be  adopted,  as  the  film  has 
the  advantage  of  showing  a  much  clearer  detail  of  the  anatom- 
ical structures,  thereby  affording  a  better  outline  for  the  study 
of  the  many  minute  normal  and  abnormal  phases  which  should 
be  taken  into  account  in  connection  with  an  extraction  of  the 
involved  tooth. 

Extraoral  Radiograph. — To  obtain  an  extraoral  picture,  a 
photographic  plate  is  used  instead  of  the  film.     The  plate  is 


WHEN  RADIOGRAPH  IS  INDICATED  89 

protected  from  the  action  of  dayligiit  by  inserting  it  in  a  double 
envelope  made  especially  for  this  purpose,  or  it  can  be  deposited 
in  a  regular  plate  holder.  The  plates  used  for  this  work  are  of 
various  sizes,  the  operator  selecting  such  size  as  will  give  the 
amount  of  surface  he  desires  to  secure.  The  extraoral  method 
of  obtaining  a  picture  is  used  where  it  is  impracticable  or  impos- 
sible to  put  the  small  film  into  the  mouth,  as  where  the  area  is 
painful,  or  where  the  tooth  is  situated  in  the  posterior  part  of 
the  mouth  and  the  tissues  are  very  sensitive,  and  also  in  a  case 
where  temporary  ankylosis  is  established  and  the  patient  is 
unable  to  open  the  mouth. 

WHEN  THE  RADIOGRAPH  IS  INDICATED. 

Probably  the  most  important  use  that  can  be  made  of  the 
radiograph  in  examination  is  in  all  forms  of  impacted  teeth. 

Impacted  Tooth. — When  a  tooth  is  impacted  and  missing  from 
its  usual  position  in  the  arch,  an  examination  of  the  parts  where 
the  tooth  should  be  normally  situated  is  made.  Considerable 
knowledge  concerning  the  tooth  can  usually  be  gained  by  pass- 
ing the  fingers  over  the  gum  tissue,  and  noting  whether  there  is 
a  bulging  of  the  alveolus,  or  whether  a  part  of  a  cusp  of  a  tooth 
is  protruding  through  the  soft  tissues.  An  inflamed  area  or 
pus  infection  of  the  tissues  in  the  suspected  region  of  the  im- 
pacted tooth  usually  denotes  its  presence. 

In  the  case  of  an  impacted  tooth  the  use  of  the  radiograph  is 
a  humanitarian  aid  to  a  speedy  diagnosis.  Before  the  develop- 
ment of  rontgenography,  operations  on  impacted  teeth  were 
made,  owing  to  imperfect  diagnosis,  with  a  feeling  of  uncertainty 
as  to  the  possible  delivery  of  the  tooth  in  fofo  from  its  socket, 
and  any  such  feeling  of  uncertainty  has  a  tendency  to  militate 
against  the  success  of  the  operation. 

When  a  radiograph  of  an  impacted  tooth  has  been  obtained, 
the  diagnostic  points  to  be  interpreted  are  its  location  as  com- 
pared with  its  normal  position,  its  relation  to  the  adjacent  teeth, 
the  contact  point  that  interferes  with  its  proper  eruption,  the 
shape  and  size  of  the  crown  and  root  or  roots,  and  any  abnor- 
malities that  may  be  present.  An  estimate  is  made  of  the 
amount  of  alveolar  process  involved,  the  space  through  which 
the  tooth  in  question  must  be  extracted,  and  the  uiost  favorable 


90  EXAMINATION  OF  MOUTH  AND  TEETH 

direction,  taking  into  consideration  its  long  axis,  in  which  the 
imbedded  tooth  can  be  removed  from  its  position. 

Deep-Seated  Root. — The  radiograph  is  indicated  in  the  case 
of  a  root  that  is  deeply  seated  in  the  tissues,  especially  if  a 
large  amount  of  soft  tissue  overlies  the  root  of  the  tooth  and  its 
location  is  obscure.  The  advantages  presented  by  the  radio- 
graph in  such  case  are  that  it  will  reveal  the  size  and  location 
of  the  root,  the  depth  of  the  root  in  the  tissue,  and  the  amount 
of  tissue  that  may  be  involved.  From  the  picture  the  operator 
can  determine  the  manner  in  which  the  root  can  l)e  extracted 
with  the  least  amount  of  destruction  to  the  tissue  and  the  method 
of  applying  the  instrument  to  make  certain  the  delivery  of  the 
root.  Remarkable  deviations  from  the  normal  are  revealed  in 
many  instances  by  an  x-ray  picture  of  the  root.  A  frequent 
abnormal  condition  of  the  root  of  a  tooth  is  hypercementosis,  and 
where  this  condition  prevails  a  great  deal  of  tentation  may  be 
avoided  l)y  being  aware  of  its  presence. 

Suspected  Unextracted  Root. — A  case  is  often  presented 
where  a  i)atient  will  state  that  a  former  oj^erator  had  presum- 
ably extracted  a  tooth,  but  the  patient  feels  that  the  operation 
was  not  complete  and  that  a  part  of  the  tooth  remains.  In  such 
a  case,  if  the  socket  is  inflamed  and  the  parts  are  sensitive,  it  is 
usually  impossible  to  introduce  a  suitable  probe  to  make  a 
thorough  examination.  The  radiograph  will,  however,  deter- 
mine whether  a  part  of  a  root  is  present,  and  will  at  the  same 
time  give  an  outline  of  the  socket,  so  that  it  can  be  treated 
according  to  the  condition  revealed. 

Tooth  or  Root  Below  a  Bridge. — Where  the  sharp  edge  of  a 
part  of  a  root  or  the  cusp  of  an  unerupted  tooth  appears  under 
a  bridge  that  is  permanently  cemented  in  place,  it  is  frequently 
the  case  that  the  relative  position  of  the  bridge  and  imbedded 
root  or  tooth  cannot  be  determined  by  an  external  examination. 
If  it  is  suspected  that  an  attempted  extraction  would  endanger 
the  work,  a  radiograph  should  be  made,  which  will,  in  addition 
to  outlining  the  size  of  the  imbedded  tooth  structure,  show  its 
relation  to  the  artificial  restoration,  and  make  it  possible  to 
operate  in  many  cases  without  disturliing  the  bridgework. 

Abscessed  Tooth. — Often  in  the  case  of  an  abscessed  tooth  the 
operator  desires  to  gain  a  knowledge  of  the  extent  of  the  affected 
region  and  the  amount  of  bone  tissue  that  has  been  attacked. 


WHEN  RADIOGRAPH  IS  INDICATED  91 

A  radiograph  will  readily  disclose  the  condition,  and  the  abscess 
will  be  recognized  by  a  dark  area  in  the  picture.  On  completion 
of  the  extraction  the  after-treatment  should  be  according  to  the 
information  conveyed  by  the  radiograph. 

Unerupted  Tooth. — The  radiograph  is  often  indicated  in  the 
case  of  an  unerupted  tooth  in  order  to  locate  it  and  determine 
whether  it  has  a  tendency  to  assume  a  normal  position  in  the 
arch.  Freakish  and  unusual  positions  are  sometimes  assumed 
by  unerupted  teeth,  causing  annoyance  and  intense  suffering. 
Nothing  is  gained  by  a  delayed  diagnosis,  and  it  is  better  to 
resort  to  the  x-ray  in  order  to  clearly  define  the  condition  of  the 
postponed  eruption. 

Deciduous  Tooth. — The  radiograph  is  also  used  in  the  case  of 
a  deciduous  tooth  where  the  root  is  interfering  with  the  proper 
eruption  of  the  permanent  tooth,  or  where  the  operator  has  rea- 
son to  suspect  that  the  extraction  of  the  deciduous  tooth  is  liable 
to  endanger  the  permanent  tooth. 

Maxillary  Sinus. — The  radiograph  is  a  great  aid  in  diagnosing 
any  disturbance  of  the  maxillary  sinus.  Where  the  operator 
is  unable  to  decide  whether  to  treat  the  sinus  through  the  pulp 
canal  or  to  extract  the  tooth  in  order  to  proceed  with  the  treat- 
ment, the  radiograph  will  so  clear  up  the  situation  that  the 
operator  can  decide  which  course  to  pursue. 

Other  Conditions. — In  addition  to  the  cases  mentioned  for  the 
use  of  the  radiograjjh,  it  is  employed  in  extensive  fracture  of  the 
alveolar  process  in  order  to  gain  some  idea  of  the  size  of  the 
fracture,  and  to  ascertain  whether  the  fractured  process  should 
remain  or  l)e  removed.  In  a  case  where  the  operator  has  reason 
to  suspect  that  the  tul)erosity  about  the  superior  third  molar 
may  have  been  fractured  by  a  previous  operation,  the  radio- 
graph will  determine  whether  there  is  a  fracture,  and,  if  a  frac- 
ture is  revealed,  its  extent,  together  with  the  best  possible  way 
to  treat  it,  will  be  indicated  by  the  radiograph. 

The  radiograph  is  advantageously  employed  in  abnormal  con- 
ditions and  diseases  of  the  maxilla  and  mandible,  such  as  ne- 
crosis, fracture,  etc.,  and,  in  fact,  it  should  be  used  previous  to 
every  operation  where  a  correct  diagnosis  is  otherwise  question- 
able. When  the  operator  finds  that  the  radiograph  is  the  means 
of  minimizing  the  possil)ility  of  disappointment  and  disaster, 
and  materially  aids  him  in  his  operative  technic,  he  will  take  the 


92  EXAMINATION  OF  MOUTH  AND  TEETH 

l^recaiition  to  employ  it  in  all  complicated  cases.  The  only  objec- 
tion that  may  be  advanced  against  the  nse  of  the  radiograph 
is  that  of  cost,  but,  when  the  possible  dangerous  results  of  an 
incorrect  diagnosis  are  taken  into  consideration,  with  the  at- 
tending loss  of  time,  unnecessary  pain,  and  annoyance  caused  by 
other  methods  of  examination,  the  radiograph  will  be  found  a 
profitable  investment  and  certainly  more  reliable. 

Procedure  Outlined. — At  the  conclusion  of  an  examination  the 
operator  should  jjossess  a  clear  mental  picture  of  existing  condi- 
tions, from  which  he  is  to  carefully  outline  the  operative  pro- 
cedure that  is  to  follow.  As  far  as  possible,  each  movement 
should  1)0  studied  out  in  advance,  formulating  at  the  same  time 
the  methods  to  be  adopted  to  meet  any  contingencies  that  may 
arise  during  the  operative  procedure,  which  will  enable  the 
operator  to  accomplish  the  desired  end  in  the  most  practicable 
manner  that  Conditions  will  permit.  Such  a  course  will  inspire 
the  operator  with  confidence,  rendering  him  selfpossessed  in 
demeanor  and  deliberate  in  execution,  with  every  movement 
under  perfect  control.  All  unnecessary  movements  should  be 
avoided,  and  the  first  adjustment  of  the  forceps  or  elevator 
should,  if  possible,  be  the  final  one. 


CHAPTER  YII. 
POSITION  OF  THE  PATIENT  AND  OPERATOR. 

In  the  extraction  of  teeth  the  rehitive  positions  of  the  j^atient 
in  the  chair  and  the  operator  are  very  important  featnres  to  be 
observed.  The  position  of  the  patient  should  be  as  comfortable 
as  possible,  taking  into  consideration  the  location  of  the  tooth 
to  be  extracted.  The  position  of  the  operator  should  be  such 
as  to  give  an  unobstructed  view  of  the  operating  held  and  permit 
a  direct  application  of  the  instrument,  so  that  the  extraction 
movements  can  be  properly  executed  and  the  tooth  safely  con- 
veyed from  the  oral  cavity.  The  particular  positions  of  the 
operator  for  extracting  the  different  teeth  and  the  method  of 
exposing  the  operating  field  are  described  respectively  under 
headings  pertaining  to  the  extraction  of  the  various  teeth. 

POSITION  FOR  OPERATION  ON  THE  SUPERIOR 

TEETH. 

Position  of  the  Patient  for  Operation  on  the  Superior  Teeth. — 

The  patient  should  sit  erect,  with  the  head  in  line  with  the  axis 
of  the  body.  The  chair  should  be  so  adjusted  that  the  body  will 
be  thoroughly  supported,  both  as  to  the  back  and  head,  when 
the  muscles  are  relaxed,  and  not  interfere  with  free  breathing. 
The  position  of  the  body  in  the  chair  is  seldom  changed,  a  higher 
or  lower  position  being  obtained  by  adjusting  the  chair.  It  will, 
however,  be  necessary  to  so  arrange  the  posture  of  the  head  as 
to  conform  to  the  position  required  for  the  extraction  of  any 
particular  tooth,  and  it  may  be  necessary  to  turn  the  head  side- 
wise  in  the  head-rest,  which  should  be  of  sufficient  size  to  pre- 
vent the  head  from  slipping  from  the  desired  position.  The 
head-rest  should  be  so  constructed  that  it  is  easily  adjusted,  and 
allow  the  arm  of  the  operator  to  be  readily  placed  around  the 
head  of  the  patient  to  assist  in  supporting  the  head  when  the 
nature  of  the  extraction  requires  such  support.  The  arms  of 
the  patient  should  be  relaxed,  with  the  hands  h'ing  loose  in  his 

93 


94  POSITION  OF  PATIENT  AND  OPERATOR 

lap.  If,  however,  the  patient  is  of  a  nervous  temperament,  the 
operator  may  instruct  him  to  clasp  his  hands  together.  If  a 
general  anesthetic,  such  as  nitrous  oxid  and  oxygen,  is  to  be 
administered  to  a  nervous  person,  the  operator  may  instruct 
him  to  follow  the  psychologic  demonstration  of  raising  and  low- 
ering the  index  finger  of  his  left  hand,  which  will  usually  distract 
his  mind  from  the  operation.  The  limbs  of  the  patient  should 
be  rehixed  and  not  crossed,  and  his  feet  should  rest  solidly  on 
the  foot-rest  of  the  operating  chair. 

The  operating  chair  should  be  adjusted  to  a  height  to  suit  the 
stature  of  the  oi)erator,  with  the  head  of  the  patient  about  in 
line  with  the  shoulder  of  the  operator.  This  position  insures  a 
good  access  to  the  tooth,  and  at  the  same  time  jDermits  the  ex- 
traction movements  to  Ije  made  in  their  regular  order.  No  tilt 
of  the  chair  is  necessary,  except  in  very  rare  cases  with  the  third 
molar  when  that  tooth  is  obscured  by  the  tissues. 

If  the  operator  anticipates  any  interference  from  the  patient 
during  the  operative  procedure  when  a  general  anesthetic  is  not 
emi^loyed,  he  should  inform  the  patient  that  any  interference 
with  the  operator's  hands  will  affect  the  results  to  be  obtained. 
Such  interference  is  not  only  a  hindrance  to  the  operator,  with 
the  effect  of  prolonging  the  operation,  but  frequently  causes  a 
disagreeable  fracture  of  a  tooth.  The  operator's  assistant,  who 
stands  to  the  left  of  the  chair,  should  always  be  on  the  alert  to 
prevent  the  hands  of  the  patient  from  getting  in  the  way  during 
the  operation. 

Position  of  the  Operator  when  Employing  Forceps  on  the  Su- 
perior Teeth. — The  position  of  the  operator  when  operating  on 
the  superior  teeth  is  to  the  right  of  the  operating  chair  (Fig. 
52).  His  body  should  be  w^ell  balanced,  and  his  feet  should  rest 
solidly  on  the  floor,  be  free  of  the  base  of  the  operating  chair, 
and  so  placed  that  they  can  not  slip.  His  limbs  should  be 
slightly  separated,  but  straight,  and,  when  the  forceps  are  ap- 
plied and  the  extraction  movements  begun,  are  slightly  bent 
during  the  tractile  movement. 

For  the  extraction  of  an  anterior  tooth — for  example,  the  cen- 
tral incisor — the  operator  stands  to  the  right  of  the  patient, 
stepping  slightly  to  the  rear  as  he  progresses  to  the  posterior 
teeth  on  the  right  side  of  the  arch  if  any  of  those  teeth  are  to  be 
extracted.     For  an  anterior  tooth  on  the  left  side  of  the  arch, 


POSITION  FOR  OPERATION  ON  SUPERIOR  TEETH 


95 


his  position  advances  toward  the  front  of  the  patient,  and,  as  lie 
proceeds  to  the  posterior  teeth  on  the  left  side  of  the  arch,  it  will 
become  necessary  for  him  to  step  slightly  to  the  rear  and  lean 
fnrther  over  the  patient,  so  that  he  inclines  well  toward  the  left 
of  the  j^atient. 


Fig.   52. — Position  of  the  optiaiur  when  applying  forceps  to  superior  teeth. 

If  a  number  of  teeth  are  to  be  extracted,  involving  both  sides 
of  the  arch,  the  operator  starts  on  the  left  side,  the  most  pos- 
terior teeth  or  roots  being  extracted  first,  and  operates  forward, 
following  the  order  of  extraction  to  the  central  incisors;  then, 
changing  to  the  right  side  of  the  arch,  the  most  posterior  teeth 


96  POSITION  OF  PATIENT  AND  OPERATOR 

on  that  side  are  extracted,  and  he  again  operates  forward,  fol- 
lowing the  same  order  of  extraction  to  the  central  incisors.  Es- 
l^ecially  should  this  method  be  followed  when  a  general  anes- 
thetic is  employed. 

POSITION  FOR  OPERATION  ON  THE  INFERIOR 

TEETH. 

Position  of  the  Patient  for  Operation  on  the  Inferior  Teeth. — 

The  position  of  the  patient  in  the  chair  is  similar  to  that  for 
operation  on  the  superior  teeth  (page  93).  The  head  is,  how- 
ever, brought  slightly  further  forward  by  adjusting  the  head- 
rest. 

The  operating  chair  is  placed  as  low  as  possible  for  all  inferior 
teeth,  and  tilted  slight  l)ackward  for  the  ten  anterior  teeth,  the 
tilting  being  still  a  little  further  backward  for  the  posterior 
teeth.  If  anterior  and  posterior  teeth  are  to  be  extracted 
at  the  same  sitting,  the  position  should  be  as  if  only  posterior 
teeth  were  to  be  extracted.  The  chair  should,  however,  be  tilted 
forward  as  soon  as  the  operation  is  completed. 

Inferior  teeth  present  more  complex  operations  than  superior 
teeth  because  of  the  mobility  of  the  mandible,  which,  coupled 
with  interference  from  the  tongue,  renders  application  of  the 
forceps  more  difficult,  and  care  is  necessary  not  to  injure  the 
tissue  or  strike  the  superior  teeth  in  the  tractile  movement  up- 
ward or  when  carrying  the  tooth  from  the  mouth. 

Position  of  the  Operator  when  Employing  Forceps  on  the 
Inferior  Teeth. — The  oi)erator  assumes  a  i)osition  back  of  the 
patient.  When  ready  to  apply  the  forceps,  he  steps  on  a  stool  or 
platform  in  the  rear  of  the  operating  chair  and  inclines  his  body 
forward  (Pig.  53),  with  limbs  slightly  flexed  at  the  knees.  When 
the  upward  tractile  movement  is  begun,  a  straightening  of  the 
limbs  will  increase  the  lifting  power.  As  when  operating  on  the 
superior  teeth,  his  feet  should  rest  solidly  on  the  surface  on 
which  he  stands.  In  the  position  described  the  operator  is 
directly  over  the  inferior  cuspid,  and  in  line  with  the  axis  of  the 
root.  As  he  approaches  the  posterior  teeth  on  either  side  of  the 
arch,  he  inclines  his  body  correspondingly  to  the  right  or  left  to 
maintain  his  position  in  line  with  their  axes.  This  procedure 
has  the  advantage  of  permitting  a  direct  application  of  the  for- 
ceps to  all  of  the  inferior  teeth,  while  any  desired  amount  of 


POSITION  FOR  OPERATION  ON   INFERIOR  TEETH  97 

pressure  can  be  accurately  gauged  and  directed  in  line  with  the 
axes  of  the  roots,  and  the  extraction  movements  can  also  be  car- 
ried out  freely.  Another  advantage  is  that  the  tooth  under  oper- 
ation is  in  view  throughout  the  entire  procedure,  the  value  of 
which  will  be  fully  recognized  in  case  complications  arise.     The 


Fig.  53. — Position  of  the  operator  when  applying  forceps  to   inferior  teeth. 

direct  pressure  afforded  will  frequently  deliver  an  anterior  tooth 
from  the  socket  under  its  initial  application,  and  this  position  is 
advantageously  employed,  especially  when  using  the  improved 
molar  forceps  (Fig.  13),  with  the  molar  teeth,  where  the  field  is 
often  quite  obscured. 


98  POSITION  OF  PATIENT  AND  OPERATOR 

The  position  usually  assumed  is  at  the  right  side  and  toward 
the  front  of  the  patient — almost  similar  to  that  used  for  the  supe- 
rior teeth,  being  only  more  to  the  front  of  the  patient.  While 
this  position  may  conmiend  itself  to  some,  the  author  believes  it 
has  several  serious  drawbacks.  The  introduction  of  the  forceps 
obscures  the  view  of  the  field  of  operation,  and  the  line  of  force 
applied  in  directing  the  forceps  downward  to  grasp  the  neck  of 
the  tooth  is  at  such  an  angle  that  it  requires  a  much  stronger 
wrist  action  and  firmer  grasp  on  the  forceps  than  are  necessary 
when  the  operator  is  above  the  patient.  There  is  also  a  greater 
probability  to  misjudge  the  exact  axis  of  the  tooth,  and,  if  mis- 
judged, will  cause  an  insecure  grip  to  be  taken  on  the  tooth. 
Even  if  a  firm  grip  is  secured  and  the  extraction  movements  are 
begun,  greater  judgment  is  required  to  execute  them  correctly, 
as  all  force  is  applied  at  an  angle  instead  of  in  a  straight  line, 
and  as  a  consequence  the  tooth  may  be  easily  fractured.  If  the 
space  for  the  passage  of  the  tooth  is  limited,  the  application  of 
the  forceps  is  more  difficult  when  working  at  an  angle  than  when 
operating  in  a  straight  line.  The  operator  will  find  that  he  can 
exert  more  force  in  a  direct  line  than  at  an  angle,  not  to  mention 
the  increased  power  and  better  control  of  arm  and  hand  that  can 
be  exercised  when  the  arm  is  partially  flexed,  a  position  given 
the  arm  when  the  operator  is  back  of  the  patient. 

POSITIONS  FOR  VARIOUS  CONDITIONS. 

Position  of  the  Operator  when  Employing  Forceps  where 
Superior  and  Inferior  Teeth  are  to  be  Extracted  at  the  Same 
Sitting. — When  one  is  accustomed  to  both  superior  and  inferior 
positions,  changing  quickly  from  one  to  the  other  becomes  a  mat- 
ter of  habit.  In  the  majority  of  cases  the  extraction  of  the  in- 
ferior teeth  precedes  operating  on  the  superior  teeth,  and  the 
operator  accordingly  assumes  the  position  for  extracting  the 
former.  When  the  operator  has  completed  the  extraction  of  the 
inferior  teeth,  he  quickly  tilts  the  operating  chair  forward,  steps 
down — right  foot  first — from  the  foot-stool  on  which  he  has  been 
standing,  and  assumes  the  position  for  extracting  the  superior 
teeth. 

The  position  to  the  left  of  the  patient  is  rarely,  if  ever,  re- 
quired for  the  superior  teeth.  The  author  does  not  recall  a  case 
where  it  became  necessary  to  step  to  the  left  when  operating  on 


POSITIONS  FOR  VARIOUS  CONDITIONS  99 

this  arch.  Such  change  of  position  is,  however,  occasionally 
necessary  when  operating-  on  the  inferior  arch,  as,  for  example, 
in  the  case  of  a  right  inferior  bicuspid  or  third  molar  when  these 
teeth  are  out  of  alignment  and  displaced  to  the  lingual  side  of 
the  arch,  being  directed  toward  the  tongue,  when  it  is  advisable 
to  use  forceps  indicated  for  the  superior  teeth  and  operate  from 
the  left  side  in  order  to  secure  direct  access  to  the  tooth. 

Position  of  the  Operator  when  Employing  an  Elevator. — The 
position  of  the  operator  for  using  the  elevator  is  on  the  right  side 
of  the  23atient.  The  elevator  is  held  in  the  right  hand,  the  left 
hand  being  employed  to  control  the  soft  tissue  of  the  mouth,  so 
as  to  keep  it  out  of  the  way  of  the  instrument  and  to  admit  light, 
and  also  to  give  support  to  the  jaw,  adjacent  teeth,  and  alveo- 
lar process  wherever  necessary.  The  majority  of  elevators,  as 
manufactured,  have  very. short  shanks,  compelling  the  operator 
to  change  his  position  to  the  left  side  of  the  patient  for  teeth  on 
that  side  of  the  arch.  The  author  has,  however,  overcome  this 
objectionable  feature,  and  has  also  increased  the  efficiency  of  the 
elevator,  by  having  an  additional  set  made  in  which  the  blade  of 
the  regular  make  is  reproduced,  but  with  the  shank  one  and  one- 
half  inches  longer,  which  he  uses  in  conjunction  with  those  of 
regular  manufacture  (Figs.  20,  23,  25).  This  improvement 
enables  him  to  operate  on  the  left  side  of  the  arch  without 
changing  to  the  left  side  of  the  patient,  with  the  following  ex- 
ceptions: where  the  inferior  bicuspids  on  the  left  side  of  the  arch 
have  deep-seated  roots,  and  direct  leverage  cannot  be  obtained 
from  the  right  side;  where  the  inferior  left  first  and  second  molar 
roots  present  considerable  resistance,  and  extraordinary  force  is 
required  to  release  them;  where  the  inferior  left  third  molar  is 
affected  on  its  mesial  surface  with  caries,  which  indicates  an 
adjustment  of  the  elevator  to  the  buccal  surface;  and  where  the 
tooth  is  out  of  alignment  or  impacted,  and  it  is  necessary  to  send 
the  tooth  toward  the  lingual  side  when  that  plate  has  been  dis- 
sected away,  as  direct  pressure  cannot  be  secured  from  the  right 
side.  When  operating  on  the  left  side,  the  operator  should  stand 
slightly  to  the  rear,  with  his  face  directed  toward  the  left  side 
of  the  patient. 

Position  of  the  Operator  when  Operating  on  a  Child. — The 
position  of  the  child  in  the  chair,  the  adjustment  of  the  chair, 
and  the  position  of  the  operator  are  i^ractically  the  same  as  for 


100  POSITION  OF  PATIENT  AND  OPERATOR 

an  adult  joerson  when  extracting  superior  or  inferior  teetli.  The 
height  of  the  patient  is,  however,  taken  into  consideration,  and 
the  newer  tj'pe  of  dental  chair  has  a  special  arrangement  for  a 
child's  position.  In  the  ordinary  chair  a  number  of  pillows  may 
be  used,  and  the  patient  can  be  jjropped  up  to  a  sufficient  height 
to  secure  good  access  and  at  the  same  time  provide  a  comfortable 
position.  The  operator  should  not  be  too  hasty  with  the  arrange- 
ment of  the  child,  and  not  frighten  it  with  the  preliminaries  to 
obtain  the  desired  position,  being  careful  that  the  child  is  so 
placed  that  it  does  not  slip  from  the  position  selected. 

In  case  the  child  is  unmanageable,  and  the  operator  deems  it 
advisable,  the  patient  may  be  taken  in  the  lap  of  the  assistant. 
If,  in  the  case  of  a  child  that  is  small  and  delicate,  a  deciduous 
tooth  is  to  be  removed  prematurely  on  account  of  some  patho- 
logic condition  that  cannot  be  treated  in  au}^  other  manner,  it 
may  be  advisable  for  the  mother  (if  she  is  not  in^  nervous  con- 
dition) or  the  nurse  accompanying  the  child  to  take  a  position 
in  the  operating  chair  and  hold  the  little  patient  in  her  lap,  care 
being  taken,  before  attempting  to  operate,  that  the  head  of  the 
child  rests  firmly  against  the  shoulder  of  the  person  holding  it. 
Such  a  position  will  usually  be  taken  with  less  apprehension  on 
the  part  of  the  child,  and  result  in  a  successful  operation  when 
without  such  course  there  would  be  a  failure  for  lack  of  sub- 
mission on  the  part  of  the  j^atient. 

Position  of  the  Operator  at  the  Home  of  the  Patient. — Occa- 
sionally it  becomes  necessary  to  operate  at  the  home  of  a  patient 
because  his  general  health  will  not  permit  him  to  go  to  the  office 
of  the  operator.  When  this  is  the  case,  the  operator  should  se- 
cure at  the  home  as  favorable  an  operating  position  as  possible 
for  the  patient  and  himself,  and  have  the  patient  placed  close  to 
as  good  a  light  as  is  obtainable.  When  practicable,  the  patient 
should  be  placed  in  a  sitting  position,  as  the  operator  is  accus- 
tomed to  such  posture,  and  it  will  aid  in  obtaining  better  results. 
This  position  may  be  secured  by  the  use  of  a  Morris  chair,  or,  if 
that  is  not  available,  by  taking  two  ordinary  chairs  with  low 
backs,  and  placing  one  in  front  of  the  other,  tandem  fashion. 
The  patient  is  seated  on  the  front  chair,  and  the  operator,  taking 
a  position  to  the  right  of  the  patient,  places  his  left  foot  on  the 
rear  chair,  with  his  knee  elevated,  covering  the  knee  with  a  towel. 
The  head  of  the  patient  is  drawn  slightly  backward,  and  made  to 


POSITIONS  FOR  VARIOUS  CONDITIONS  101 

rest  on  the  kuee  of  the  operator.  This  gives  a  fairly  comfortable 
position  for  the  patient,  and  at  the  same  time  gives  the  operator 
access  to  all  parts  of  the  oral  cavity.  If  the  condition  of  the 
patient  does  not  permit  removal  from  the  bed,  he  is  brought  as 
close  as  possible  to  its  edge,  preferably  to  the  right  side.  In  this 
position  the  head  of  the  patient  should  be  raised,  or,  if  possible, 
he  should  be  placed  in  a  sitting  position.  In  such  case  the  opera- 
tor must  incline  his  body  and  operate  as  well  as  the  circum- 
stances will  allow. 

Position  of  the  Operator  in  the  Hospital. — The  operator  se- 
cures the  best  possible  position  after  the  manner  adopted  for 
operating  at  the  home  of  the  patient  if  the  patient  is  able  to  sit 
up.  If  the  patient  is  unable  to  sit  up,  he  is  placed  on  the  operat- 
ing table,  with  the  head,  supported  by  a  pillow,  as  close  as  posi- 
ble  to  the  end  of  the  table,  and  the  parts  to  be  operated  on  made 
as  accessible  as  conditions  will  permit.  For  the  inferior  teeth 
the  operator  should  assume  a  position  back  of  the  head.  While 
operating  he  must  be  careful  to  support  the  inferior  mandible, 
and  allow  the  head  to  be  turned  to  the  left  or  right,  as  the  case 
indicates.  When  operating  on  the  superior  teeth  he  should 
stand  on  the  right  side  and  face  the  patient,  securing  as  direct 
access  as  is  possible.  When  operating  on  an  impacted  third 
molar,  it  is  preferable  to  operate  from  the  side  on  which  the 
affected  molar  may  be  located. 


CHAPTER  VIII. 
PRECAUTIONARY  SUGGESTIONS. 

In  the  practice  of  exodontia  certain  contingencies  may  be  pre- 
sented that  require  special  mention,  and  the  necessary  degree  of 
precaution  should  be  exercised  by  the  operator  to  properly  meet 
these  conditions,  as  frequently  a  successful  operation  in  a  case 
presenting  peculiar  features  will  depend  on  the  ability  of  the 
operator  to  readily  comprehend  the  condition  and  adopt  the 
correct  procedure. 

PRELIMINARY  PROCEDURE. 

Before  proceeding  to  operate,  the  crown  and  neck  of  the  tooth 
to  be  extracted,  together  with  the  associated  tissues,  should  be 
thoroughly  cleansed  by  syringing  with  a  lukewarm  antiseptic 
solution,  using  the  syringe  shown  in  Fig.  35  or  a  spray  bottle 
connected  with  a  compressed  air  apparatus.  The  neck  of  the 
tooth  should  then  be  carefully  gone  over  with  a  pledget  of  ab- 
sorbent cotton  saturated  with  alcohol  to  more  effectually  ster- 
ilize the  field  of  operation  and  to  prevent  infection  of  the  wound, 
a  condition  that  would  likely  ensue  if  the  debris  were  not 
removed,  as  it  would  in  all  probability,  if  allowed  to  remain,  be 
carried  under  the  free  margin  of  the  gum  and  into  the  wound 
during  the  operation. 

Any  salivary  calculus  that  may  be  attached  to  the  tooth 
should  be  removed  if  it  is  liable  to  interfere  with  a  free  applica- 
tion of  the  forceps  or  to  be  carried  into  the  wound.  If  pus 
exudes  from  around  the  free  margin  of  the  gum  and  continues 
to  flow  after  the  area  has  been  thoroughly  syringed,  absorbent 
cotton  or  sterilized  gauze  should  be  applied  to  absorb  the  exu- 
date, or  it  may  be  withdrawn  with  a  hypodermic  syringe.  There 
will,  however,  be  cases  where  this  method  of  temporarily  check- 
ing the  exudation  will  not  be  practicable  on  account  of  the  large 
flow  of  pus.  Where  such  condition  exists,  a  sufficient  quantity 
of  absorbent  cotton  or  sterilized  gauze  is  placed  over  the  exud- 

102 


ADVISING  PATIENT  BEFORE  OPERATION  103 

ing  area,  and,  when  the  operator  is  ready  to  apply  the  instru- 
ment, the  assistant  quickly  removes  the  cotton  or  ganze,  which 
has  in  the  meantime  absorbed  the  pus  to  such  an  extent  as  to 
permit  a  proper  application  of  the  instrument  to  the  tooth. 

TIME  OF  DAY  FOR  OPERATING. 

The  most  favorable  time  of  day  for  the  general  dental  prac- 
titioner to  extract  teeth  is  in  the  morning,  as  the  patient  is  then, 
as  a  rule,  in  the  best  physical  condition,  and  the  operator  is  not 
fatigued  with  the  work  incident  to  the  daily  routine  duties  of 
his  profession.  Such  operations  will,  however,  from  necessity 
often  be  performed  in  the  latter  part  of  the  day,  as  a  patient  will 
be  prompted  to  seek  relief  when  he  realizes  that  he  must  undergo 
"the  ordeal"  to  insure  against  another  sleepless  night.  The 
extraction  of  a  tooth  is  held  in  dread  by  the  average  patient, 
and  in  many  cases  submission  to  the  operation  is  not  yielded 
until  the  pain  becomes  unbearable,  when  the  patient  goes  in 
quest  of  immediate  relief. 

IMPAIRED  HEALTH. 

Where  the  vitality  of  the  system  of  the  patient  is  impaired 
and  he  is  in  a  debilitated  condition,  the  operation  should  be  per- 
formed in  a  hospital,  and  the  general  treatment  of  the  patient 
be  in  accordance  with  the  directions  of  the  family  physician. 

ADVISING  THE  PATIENT  BEFORE  THE  OPERATION. 

It  is  advisable  in  a  case  where  the  associated  tissues  are  in- 
fected, or  where  other  unfavorable  s^anptoms  are  present,  to 
apprise  the  patient  in  advance  of  the  operation  of  the  nature  of 
the  contemplated  extraction,  and  especially  should  this  precau- 
tion be  taken  where  any  difficulty  is  anticipated  or  where  the 
severing  of  a  consideral)le  amount  of  tissue  around  the  tooth  will 
be  unavoidable.  The  patient  should  be  given  to  understand  that 
the  extraction  of  a  tooth  involved  as  the  one  under  consideration 
will  not  always  give  immediate  relief,  and  that  it  will  be  impera- 
tive to  give  the  wound  proper  attention  after  the  tooth  has  l)een 
removed. 

The  average  patient  is  disposed  to  associate  a  certain  degree 


104  PRECAUTIONARY  SUGGESTIONS 

of  similarity  with  the  extraction  of  teeth,  and  be  under  the 
impression  that  all  such  operations  are  very  much  alike.  A 
patient  may,  for  example,  have  in  mind  a  previous  operation 
of  a  simple  character  where  the  parts  healed  immediately,  but 
the  case  under  consideration  may  be  so  entirely  different,  both 
in  character  and  extent  of  involvement,  that,  if  the  extraction 
proves  more  complicated  than  the  previous  operation,  the  work 
of  the  operator  may  be  rei>'arded  in  an  unfavorable  light.  It 
will,  therefore,  be  prudent  for  the  operator  in  such  case  to  ad- 
vise the  patient,  to  such  an  extent  as  may  be  justified  by  the 
intelligence  of  the  patient  and  the  character  of  the  operation,  as 
to  the  contingencies  that  may  arise. 

UNCERTAINTY  OF  RESISTANCE  ENCOUNTERED. 

The  degree  of  resistance  to  the  force  applied  with  the  instru- 
ment used  in  the  extraction  of  a  tooth  is  always  problematical. 
Frequently  the  tooth  has  the  appearance  of  being  easily  released 
from  its  attachment,  but  great  resistance  is  encountered  when 
the  instrument  to  remove  it  is  applied.  Then,  again,  its  extrac- 
tion may  seem  difficult,  but  the  mere  application  of  the  instru- 
ment will  release  the  tooth.  The  operator  should  always  be 
prepared  for  any  condition  that  may  arise,  keeping  in  readiness 
such  instruments  as  may  be  required  in  case  unexpected  resist- 
ance is  encountered.  He  should  also  guard  against  losing- 
control  of  the  tooth  in  case  it  is  released  from  its  socket  on  the 
initial  application  of  an  instrument. 

TOOTH  AFFECTED  BY  PYORRHEA. 

No  great  amount  of  force  is  necessary,  as  a  rule,  to  detach 
from  its  supporting  tissues  a  tooth  affected  by  pyorrhea  alveo- 
laris.  It  is  advisable  not  to  apply  to  such  a  tooth  all  the  extrac- 
tion movements  that  might  be  considered  necessary  for  the  same 
tooth  if  not  so  affected,  and  only  such  movements  should  be 
executed  as  may  be  required  to  sever  the  attachment.  The 
pressure  of  the  beaks  of  the  forceps  on  the  tooth,  or  only  a  slight 
movement  laterally,  will  often  release  it,  but  precaution  should 
1)6  taken  against  tearing  the  soft  tissues  when  carrying  the  tooth 
from  its  socket,  as  they  often  adhere  more  firmly  than  is  super- 
ficially indicated,  and  especially  should  care  be  exercised  in  a 


UNSUCCESSFUL  OPERATION  BY  ANOTHER  OPERATOR  105 

case  wliere  the  tooth  is  very  loose  and  held  m  place  only  by 
these  tissues. 

UNSUCCESSFUL  OPERATION  BY  ANOTHER  OPERATOR. 

A  case  where  another  operator  has  failed  in  an  attempted 
extraction  of  a  tooth  is  usually  not  presented  until  several  days 
after  the  attempted  operation,  and  in  the  interim  the  patient  has 
probably  suffered  until  a  highly  nervous  state  supervenes  in 
addition  to  the  pain.  The  operator  should  make  a  thorough 
examination  of  all  the  affected  parts,  carefully  observing  the 
condition  of  the  soft  tissues,  alveolus,  and  the  amount  of  tooth 
structure  remaining.  If  the  pulp  is  exposed,  which  is  quite 
frequent  in  such  a  case,  it  should  not  be  disturbed  with  the 
exploring  instrument,  as  the  explorer  can  be  j^laced  against  the 
marginal  edge  of  the  part  remaining  to  determine  the  degree 
of  firmness  with  which  it  may  be  attached.  If  the  tooth  does 
not  contain  a  vital  pulp,  the  explorer  can  be  placed  in  the  pulp 
chamber  or  root  canal,  and  the  amount  of  mobility  ascertained. 
In  case  several  days  have  elapsed  since  the  previous  operation, 
the  peridental  membrane  is  usually  congested  and  the  tooth 
somewhat  loosened,  which  will  tend  to  simplify  the  operation. 
In  addition  to  examining  the  parts  mentioned,  the  teeth  adjacent 
to  the  tooth  to  be  extracted  should  be  inspected,  as  the  previous 
effort  to  release  the  tooth  may  have  loosened  other  teeth  without 
the  patient  being  conscious  of  the  occurrence,  and  the  contem- 
plated operation  will  unavoidably  dislodge  the  loosened  teeth,  in 
which  case  the  patient  will  in  all  probability  censure  the  opera- 
tor if  he  has  not  previously  explained  the  existing  condition. 
At  the  same  time  an  examination  should  be  made  to  determine 
whether  the  maxillary  sinus  or  tuberosity  is  involved  where  the 
tooth  is  situated  in  close  proximity  to  either  of  these  parts. 

While  making  the  examination  it  should  be  the  object  of  the 
operator  to  ascertain  the  cause  of  the  failure  of  the  previous 
operation,  which  may  have  been  caused  by  a  misapplication  of 
the  forceps,  lack  of  access,  abnormal  condition  of  the  alveolar 
process,  improperly  applied  extraction  movements,  or  interfer- 
ence of  the  patient.  During  the  preliminaries  the  patient  may 
take  occasion  to  express  an  unfavorable  opinion  of  the  previous 
attempts  at  extraction,  but  it  is  advisable  for  the  operator  to 
diplomatically  refrain  from  engaging  in  any  censurable  discus- 


106  PRECAUTIONARY  SUGGESTIONS 

sion  of  the  matter.  Where  a  number  of  attempts  at  clitferent 
times  have  been  made  to  extract  a  tooth,  the  patient  will,  as  a 
rule,  voluntarily  give  the  history  of  these  attempts,  and  in  such 
case  there  is  usually  found  an  abnormality  connected  with  the 
tooth  that  was  not  indicated  by  a  superficial  examination.  The 
operative  teclmic  in  these  cases  is  described  under  headings 
pertaining  to  the  extraction  of  the  various  teeth. 

In  all  cases  where  unsuccessful  attempts  at  extraction  have 
been  made  it  is  advisable  to  administer  a  general  anesthetic,  as 
it  will  sometimes  be  necessary  to  prolong  the  operation  on  ac- 
count of  peculiar  existing  conditions. 

TEMPORARY  ANKYLOSIS. 

Occasionally  temporar}^  ankylosis  is  present  in  a  case  where 
extraction  is  indicated.  This  condition  is  a  partial  or  total 
temporary  closure  of  the  jaws,  but,  as  a  rule,  the  teeth  are  not 
held  in  complete  occlusion,  and  a  slight  space  can  be  obtained 
between  the  superior  and  inferior  teeth.  While  there  are  quite 
a  number  of  affections  that  may  cause  temporary  ankylosis,  the 
most  frequent  cause  is  an  inflammatory  condition  produced  by 
the  malposition  or  delayed  eruption  of  an  inferior  third  molar, 
and  sometimes,  but  rarely,  of  a  superior  third  molar. 

Access  to  the  affected  tooth  is  the  first  step  to  be  considered, 
but  opening  the  mouth  for  this  purpose  cannot,  in  many  cases, 
be  accomplished  without  causing  the  patient  great  pain  on 
account  of  the  rigidity  of  the  muscles  and  the  extreme  sensitive- 
ness of  the  area  involved,  unless  a  general  anesthetic  is  admin- 
istered. When  the  patient  has  been  anesthetized,  the  jaws  are 
gradually  separated  with  the  wooden  wedge  (Fig.  39),  which 
is  adjusted  preferably  between  the  posterior  teeth,  avoiding,  if 
possible,  those  that  support  artificial  crowns  and  those  that  are 
weakened  by  caries.  If  it  is  not  practicable  to  open  the  mouth 
to  its  full  extent  with  the  wooden  wedge,  a  further  separation 
of  the  jaws  can  be  gained  with  the  Allen  mouth-gag  (Fig.  38). 
When  the  mouth  lias  l)een  o]iened  sufficiently  to  permit  the 
adjustment  of  the  instrument  to  the  tooth  to  be  removed,  the 
jaws  may  be  held  o]ien  with  the  Allen  or  Doyen-Jausen  mouth- 
gag,  or  with  a  mouth-prop. 

Where  temporary  ankylosis  is  caused  by  malposition  of  a 
tooth,  the  inflammation  subsides  on  its  removal,  and  the  jaw 


TEMPORARY  ANKYLOSIS  107 

soon  regains  its  normal  function.  If  septic  pericementitis, 
alveolitis,  or  other  inflammation  of  the  tissues  is  associated  with 
the  temporary  ankylosis,  the  affected  parts  are  treated  as  de- 
scribed for  these  conditions  in  "Treatment  After  Extraction" 
(Chapter  XV). 


CHAPTER  TX. 

EXTRACTION  TECHNIC  OF  THE  SUPERIOR  TEETH. 

The  extraction  of  the  superior  teeth  is  not,  as  a  rule,  as  difficult 
an  operation  as  that  of  the  removal  of  the  inferior  teeth,  as  the 
superior  teeth  are  more  accessible,  and  there  is  no  such  mobility 
of  the  maxilla  as  is  the  case  with  the  mandible.  The  superior 
teeth  are  extracted. principally  with  the  forceps,  but  such  other 
instruments  as  the  elevator,  screw-porte,  and  chisel  have  their 
special  adaptability  in  connection  with  their  removal,  and  the 
application  of  these  instruments  is  described  under  the  extrac- 
tion technic  where  their  use  is  indicated.  Special  care  should  be 
taken,  when  operating-  on  the  superior  teeth,  to  protect  the 
cuspid  eminence,  maxillary  sinus,  and  maxillary  tuberosity  from 
injury. 

SUPERIOR  CENTRAL  INCISOR. 

The  extraction  of  the  superior  central  incisor  when  the  greater 
part  of  the  crown  is  intact,  if  the  extraction  technic  is  properly 
executed,  is  a  very  simple  operation.  When,  however,  the  tooth 
is  extensively  attacked  by  caries,  some  difficulty  will  be  en- 
countered in  certain  cases.  Access  to  the  tooth  is  favorable  and 
abnormalities  are  not  frequent.  Fig.  54  shows  the  various  types 
of  superior  central  incisors  that  are  usually  seen. 

Position  of  Patient  and  Operator. — The  patient  is  properly 
seated  in  the  chair,  and  the  operator  assumes  the  position  for 
extracting  superior  teeth  (page  94).  The  left  arm  of  the  opera- 
tor is  placed  around  the  head  of  the  patient,  with  the  palm  of 
the  hand  over  the  left  cheek.  The  index  finger  raises  the  upper 
lip,  exposing  the  field  of  operation;  the  second  finger  passes  into 
the  mouth  in  the  region  of  the  superior  cuspid  on  the  left  side, 
with  the  tip  of  the  finger  extending  to  the  right  cuspid;  the  third 
finger  is  placed  on  the  labial  surface  of  the  inferior  teeth,  and 
prevents  the  forceps  from  impinging  on  the  lower  lip  (Fig.  55). 
This  position  of  the  arm  and  hand,  in  addition  to  affording  an 
open  field  for  the  operation,  gives  the  operator  an  easy  and  at 

108 


SUPERIOR  CENTRAL  INCISOR 


109 


Fig    54. — Types  of  superior  central  incisors.     The  first  row  shows  the  labial,  the  second 
row  the"  lingual,  the  third  row  the  mesial,  and  the  fourth  row  the  distal  surface. 


110 


EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 


the  same  time  a  secure  hold  of  the  patient's  head,  and,  when  the 
extraction  movements  have  begun,  enables  him  to  keep  the  head 
in  position  by  holding  it  firmly  against  the  head-rest  of  the 
operating  chair. 


Fig.  55.- — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  a  superior  incisor.  Illustration  shows  the  application  of  forceps  (Stand- 
ard No.  1)  to  the  superior  left  central  incisor. 

Forceps. — The  forceps  usually  employed  in  the  extraction  of  a 
superior  incisor  are  Standard  forceps  No.  1  (Fig.  1).  Standard 
special  A  and  special  B  forceps  (Figs.  11,  12)  are  sometimes  used 
when  this  tooth  is  partially  displaced  labially  or  lingually.  The 
labial  surface  of  this  tooth  being  broader  than  the  lingual,  it  has 


SUPERIOR  CENTRAL  INCISOR  111 

been  claimed  that  forceps  with  a  narrowed  lingual  beak  should 
be  employed  in  its  removal,  but  the  narrowing  of  the  beak  on  the 
lingual  side  is  of  little  or  no  importance.  The  only  occasion 
where  the  oi)erator  would  use  different  forceps  is  when  extract- 
ing other  teeth  at  the  same  sitting,  in  which  case,  if  the  teeth 
are  not  hrmly  attached,  they  may  be  removed  with  Standard 
forceps  No.  2  (Fig.  2).  Especially  would  there  be  occasion  to 
employ  Standard  forceps  No.  2  if  operating  under  a  general 
anesthetic,  where  time  is  always  valuable,  and  they  were  to  be 
used  in  the  removal  of  other  teeth,  which  would  obviate  the 
change  of  instruments,  with  the  consequent  loss  of  time- 
Order  of  Extraction. — In  a  case  where  it  is  necessary  to  remove 
an  adjacent  lateral  at  the  same  sitting,  the  extraction  of  the  cen- 
tral incisor  should,  whenever  possible,  precede  that  of  the  lateral. 
This  order  will  often  enable  the  operator  to  secure  a  better  adap- 
tation with  the  beaks  of  the  forceps  on  the  lateral,  but  this  order 
should  not  be  followed  when  the  central  is  the  more  difficult  to 
remove. 

Application  of  Forceps. — Having  selected  the  forceps,  applica- 
tion is  made  to  the  tooth  by  first  adjusting  one  beak  to  its  lingual 
surface  and  then  the  opposite  beak  to  the  labial  surface.  The 
hand  is  slipped  down  to  the  ends  of  the  handles  until  their  swell- 
ends  rest  in  the  palm  of  the  hand,  and  with  sufficient  pressure  the 
beaks  are  sent  up  under  the  free  margin  of  the  gum  to  the  edge 
of  the  alveolar  process,  the  beaks  being  tightened  enough  at  the 
same  time  to  grasp  the  tooth  firmly.  If  this  movement  is  care- 
fully i)erformed,  sufficient  pressure  can  often  be  exerted  while 
executing  it  to  loosen  the  tooth  from  its  attachment.  The  oper- 
ator should  be  sure  that  the  forceps  are  adjusted  in  a  direct  line 
with  the  long  axis  of  the  tooth,  for,  if  this  is  not  done,  it  will  be 
difficult  to  properly  gauge  the  amount  of  force  to  be  applied  in 
the  extraction  movements  that  are  to  follow.  This  adjustment 
should,  however,  be  comparatively  easy,  as  access  to  the  tooth  is 
not  difficult,  and  the  forceps  selected  have  the  beaks  and  handles 
in  the  same  plane. 

Alveolar  Application  of  Forceps. — The  method  of  application 
described  in  the  preceding  paragraph  will  answer  for  the  extrac- 
tion of  most  cases  of  central  incisor  in  which  there  is  enough 
structure  remaining  for  the  tooth  to  be  removed  with  Standard 
forceps  No.  1.     There  are  cases,  however,  where  in  the  applica- 


112  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

tion  of  the  forceps  it  is  necessary  to  pass  the  beaks  a  little  above 
the  edge  of  the  process,  carefully  cutting  through  this  tissue 
with  the  sharpened  beaks  before  beginning  the  extraction  move- 
ments. Such  a  condition  is  usually  found  where  the  tooth  has 
been  isolated  for  some  time,  or  where  there  is  a  loss  of  the  pos- 
terior teeth,  leaving  a  few  anterior  teeth  to  support  the  jaw. 
Nature,  in  her  effort  to  compensate  this  loss,  thickens  the  exter- 
nal plate  in  order  that  the  anterior  teeth  may  bear  the  increased 
strain  imposed  on  them.  There  are  also  instances  where  there 
is  a  large  percentage  of  mineral  matter  in  the  tooth,  which  makes 
the  tooth  brittle,  a  condition  usually  found  in  elderly  people,  in 
which  case  the  alveolar  application  is  necessary.  Unless  the 
attachment  of  the  tooth  has  been  weakened  by  disease,  greater 
care  should  be  exercised  in  its  extraction  with  persons  past 
middle  life  than  with  younger  persons,  as  the  change  which 
occurs  in  the  bony  structure  with  advancing  age  decreases  the 
liberties  that  may  be  taken  in  the  extraction  movements. 

In  the  alveolar  application  of  the  forceps,  care  should  be  taken 
not  to  force  the  beaks  too  far  over  the  process,  but  just  enough  to 
cut  through  the  crest  of  the  ridge  located  near  its  margin. 
Proper  care  in  the  extraction  of  a  tooth  l)y  this  method  will  often 
leave  the  margin  of  the  socket  in  better  condition  than  if  this 
course  had  not  been  pursued,  for,  in  addition  to  lessening  the 
danger  of  fracturing  or  bieaking  away  a  part  of  the  process  and 
leaving  the  edges  sharp  or  irregular,  the  margin  will  be  cut 
smooth,  thereby  anticipating  a  part  of  the  work  of  resorption. 
Another  advantage  is  that  there  is  less  bony  structure  to  be  cov- 
ered by  the  soft  tissue,  which  reduces  to  a  minimum  the  amount 
of  exposed  process. 

Extraction  Movements. — When  the  application  has  been  com- 
pleted (Fig.  56,  A),  and  the  tooth  has  not  been  loosened  by  such 
application,  the  extraction  movements  are  applied.  They  are 
begun  by  drawing  the  tooth  slightly  labially  (Fig.  56,  B),  and 
then  reversing  the  movement  lingually  (Fig.  56,  C),  being  cer- 
tain that  the  tooth  is  held  securely  enough  in  the  beaks  of  the 
forceps  to  actually  carry  out  these  movements,  instead  of  allow- 
ing the  beaks  to  slide  over  the  surfaces  of  the  tooth,  to  which 
there  is  a  tendency.  If  the  beaks  are  permitted  to  slide  in  such 
manner,  a  fracture  of  the  root  is  almost  certain  to  result,  as  the 
force  is  being  exerted  transversely  to  the  axis  of  the  tooth,  with 


SUPERIOR   CENTRAL  INCISOR 


11.- 


D 


E 


F 


Fig.  56. — Extraction  movements  for  superior  central  incisor.  A.  forceps  (Standard  No. 
1)  applied;  B.  first  movement  to  the  labial  side;  C,  reversed  movement  to  the 
lingual  side;  D.  rotatory  movement  from  the  labial  to  the  distal  side;  E.  reversed 
rotatory  movement  from  the  la,bial  to  the  mesial  side;  F,  tractile  movement  down- 
ward in  line  with  the  original  position  of  the  tooth. 


114  EXTRACTION  TEGHNIC  OF  SUPERIOR  TEETH 

the  process  acting  as  a  fulcrum.  The  other  extreme,  grasping 
the  tooth  too  lightly,  must  also  be  avoided,  as  by  such  course 
the  tooth  may  be  broken  off  by  the  shearing  force  thus  exerted. 
Care  and  practice  will  develop  judgment  in  this  application; 
The  first  two  movements  being  completed,  a  rotatory  movement 
is  made  by  which  the  tooth  is  slightly  turned  from  the  labial 
toward  the  distal  (Fig.  56,  D),  followed  by  a  reversed  rota- 
tory movement  from  the  labial  toward  the  mesial  (Fig.  56,  E). 
After  these  movements,  cautiously  made,  the  tooth  should  be 
loosened  from  its  attachment  and  is  delivered  from  the  socket 
with  a  tractile  movement  downward  and  in  line  with  its  original 
position  (Fig.  56,  F).  The  amount  of  force  required  to  execute 
these  movements  will  vary  with  different  teeth,  and  must  be 
carefull}^  gauged  in  each  case. 

Displacement — CompJete  Lingual. — The  superior  central  in- 
cisor is  rarely  completely  displaced  to  the  lingual  side  of  the 
arch,  and,  when  it  is  so  disi:)laced,  an  adjustment  of  Standard 
forceps  No.  1  is  made  to  the  mesial  and  distal  surfaces  in  the 
same  manner  as  in  the  case  of  the  lateral  incisor  (Fig.  61). 
When  a  firm  adjustment  has  been  secured,  the  extraction  move- 
ments are  made  by  first  bringing  the  tooth  forcibly  to  the  lingual 
side,  followed  by  the  mesial  and  distal  movements,  which  move- 
ments are  to  be  repeated,  if  necessary,  until  the  tooth's  attach- 
ment is  broken  up,  when  it  is  carried  out  of  its  socket  in  line 
with  its  original  position. 

Complete  Labial. — "Where  the  tooth  is  completely  displaced 
labially,  the  beaks  of  the  forceps  are  applied  to  the  mesial  and 
distal  surfaces.  When  applied,  the  first  extraction  movement 
should  be  toward  the  point  of  least  resistance,  which  is  necessa- 
rily to  the  labial  side.  As  the  reverse  movement  cannot  be  exe- 
cuted, owing  to  the  impingement  on  the  arch,  the  first  movement 
is  followed  by  a  slight  rotatory  movement  from  the  labial  to  the 
distal  side,  and  then  reversed.  These  movements  are  continued 
until  the  tooth  is  sufficiently  loosened  to  be  carried  from  its 
socket  in  line  with  its  axis. 

Partial. — In  case  of  partial  displacement,  either  lingually  or 
labially,  in  which  the  intervening  space  between  the  two  adjacent 
teeth  is  not  wide  enough  for  the  application  of  Standard  forceps 
No.  1,  Standard  special  A  or  special  B  forceps  are  employed,  with 
the  narrow  beak  inserted  in  the  intervening  space  to  the  labial 


SUPERIOR  CENTRAL  INCISOR  115 

or  lingual  surface  of  tiie  tooth,  depeudiug  on  the  direction  of  dis- 
placement. The  extraction  movements  are  curtailed,  but  in  the 
main  they  are  the  same  as  employed  in  the  removal  of  the  same 
tooth  in  normal  position. 

Rotated.  — Where  the  tooth  is  partially  or  completely  rotated 
in  its  socket,  the  application  of  the  forceps  should  be  made  on 
the  surfaces  that  will  permit  the  greatest  bulk  of  the  tooth  to 
be  secured  in  the  beaks  of  the  forceps.  The  extraction  move- 
ments should  be  as  near  as  possible  like  those  described  when 
the  tooth  is  in  alignment.  The  same  technic  of  application  will 
apply  to  any  other  tooth  when  rotated  in  a  like  manner. 

Caries  on  Labial  Surface.— Where  the  tooth  is  attacked  by 
caries  on  the  labial  surface,  one  beak  is  applied  to  that  surface 
first,  followed  by  applying  the  opposing  beak  to  the  lingual  sur- 
face. When  the  beaks  are  adjusted,  a  pressure  is  made  upward 
in  line  with  the  tooth's  axis.  The  labial  beak  is  watched  so  that 
it  does  not  involve  any  alveolus  unless  that  structure  is  carious; 
if  carious,  the  beak  is  sent  on  further  so  as  to  cut  through  the 
affected  part  to  secure  a  firm  hold  on  the  tooth.  The  extraction 
movement  is  made  by  carrying  the  tooth  as  forcibly  to  the  labial 
side  as  can  be  safely  done  without  fracturing  the  alveolus  or  the 
tooth,  and,  if  this  fails  to  release  it,  the  regular  extraction  move- 
ments applicable  to  this  tooth  follow,  always  using  care  to  exert 
as  little  force  as  possible  lingually,  lest  the  tooth  be  fractured. 

Caries  on  Lingual  Surface. — Where  there  is  extensive  decay 
on  the  lingual  surface,  but  with  reasonably  good  structure  on  the 
labial  surface,  extraction  is  accomplished  by  applying  one  beak 
of  the  forceps  well  up  on  the  lingual  and  bringing  the  opposite 
beak  over  the  labial  surface,  when  a  very  slight  movement 
labiall}^  will  determine  whether  the  tooth  is  secured  between  the 
beaks  of  the  forceps.  When  the  tooth  is  properly  secured,  the 
tooth  is  loosened  from  its  attachment  by  a  rotatory  movement, 
combined  with  such  labio-lingual  movement  as  can  be  safely 
applied  without  causing  a  fracture  of  the  tooth. 

Extensive  Caries. — Where  the  seat  of  caries  is  on  the  mesial 
or  distal  surface,  or  on  both  these  surfaces,  and  a  reasonably 
strong  wall  remains  on  the  labial  and  lingual  surfaces,  the  tech- 
nic of  operation  is  the  same  as  given  for  crown  and  root  intact. 
Where  caries  is  extensive,  and  little  support  can  be  had  from  the 
crown,  the  operator  should  adjust  his  forceps  independent  of  the 


116  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

crown  and  extract  tlie  tootli  as  if  he  were  operating  only  on  the 
root. 

Caries  Above  Gingival  Margin. — AVhere  the  tooth  is  decayed 
above  the  gum  margin,  and  the  hibial  and  lingual  walls  are  too 
weak  for  it  to  be  firmly  grasped  by  the  forceps,  but  where  the 
attachment  is  not  too  firm,  having  been  loosened  by  alveolitis  or 
other  cause,  extraction  may  often  be  performed  by  the  con- 
tinued force  of  application  carefully  executed  without  resorting 
to  any  of  the  other  movements  of  extraction.  The  force  of  appli- 
cation thus  executed  acts  as  a  double  wedge  through  each  beak 
of  the  forceps,  and  drives  the  root  dow^nward  between  them. 

Central  Incisor  Root. — Where  only  the  root  of  the  tooth  re- 
mains, and  decay  has  not  extended  far  up  into  the  root  canal  and 
weakened  the  outer  walls,  Standard  forceps  No.  1  are  used,  and, 
when  adjusted,  the  extraction  movements  are  followed  as  when 
no  caries  exists.  If  the  space  over  the  root  has  been  narrowed 
by  the  tipping  of  the  ai)proximating  teeth  mesially,  the  root  must 
be  brought  well  to  the  labial  side  in  its  removal  from  the  socket 
to  prevent  injury  to  these  teeth. 

Split  Root. — Frequently  the  root  of  a  tooth  is  split  its  entire 
length,  a  condition  i)robably  more  often  associated  with  a  central 
incisor  than  with  any  of  the  other  teeth.  This  tooth  is  the  most 
frequent  recipient  of  a  crown  attached  by  means  of  a  post  in  the 
pulp  canal.  Being  less  protected  than  an}'^  of  the  other  teeth, 
traumatism,  undue  stress  on  the  artificial  crown,  badly  decayed 
root  before  receiving  the  crown,  and  i)oorly  fitted  post  are  some 
of  the  common  causes  of  longitudinal  fracture  of  this  tooth. 
Where  the  root  is  in  this  condition,  the  method  of  oi)eration  is 
to  adjust  Standard  forceps  No.  1  to  both  halves  of  the  root  if 
they  are  adhering  firmly  to  the  tissues;  if  the  parts  are  not  firmly 
adhering  to  the  tissues,  the  forceps  are  applied  to  the  stronger 
section,  and  an  endeavor  made  to  carry  the  weaker  portion  from 
its  position  with  the  stronger  portion.  The  extraction  movements 
consist  in  applying  rotatory  movements  from  one  side  to  the 
other  until  the  parts  are  loosened.  For  cases  of  this  nature 
associated  with  other  teeth  the  technic  of  operation  is  the  same, 
except  the  extraction  movements  are  applied  in  accordance  with 
the  movements  peculiar  to  the  particular  tooth. 

Root  Covered  by  Gum  Tissue. — Where  decay  extends  well 
toward  the  process,  and  the  area  once  occupied  by  the  neck  of  the 


SUPERIOR  CENTRAL  INCISOR 


117 


tooth  is  nearly  covered  by  gum  tissue  (Fig.  57,  ^4),  the  tissue  may 
be  preserved  by  passing  the  closed  beaks  of  the  forceps  up  to  the 
end  of  the  root  (Fig.  57,  />),  when  the  beaks  are  carefully  opened 


."S^T- 


«'-■      /   i'-\' 


Fig.  57.— Method  of  avoiding-  the  use  of  the  lancet  where  the  gum  tissue  covers  the 
root.  A,  root  of  a  superior  central  incisor  covered  by  gum  tissue;  B,  forceps 
(Standard  No.  1)  introduced  between  the  gum  tissue;  C,  spreading  the  gum  tissue 
to  allow  the  application  of  forceps. 


sufficiently  to  pass  over  the  root  (Fig.  57,  C),  thus  dilating  the 
gum  rather  than  cutting  it.  With  the  beaks  opened  to  the  outer 
margins  of  the  root,  a  little  firm,  steady  upward  pressure  will 


118  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

usimlly  suffice  to  force  it  from  its  position,  as  such  a  root  is  sel- 
dom firmly  attached. 

Screw-Porte.— The  use  of  the  screw-porte  (Figs.  28,  29,  30) 
for  extraction  is  more  applicable  to  the  central  incisor  than  to 
any  other  tooth,  and  this  instrument  is  indicated  where  the  tooth 
has  been  fractured  above  the  process  by  traumatism  or  by  a  pre- 
vious attempt  at  extraction.  It  may  be  used  also  on  roots  re- 
duced by  decay  that  has  extended  well  above  the  process,  but 
where  the  remaining  structure  is  firm.  The  application  of  the 
instrument  and  the  extraction  movements  being  practically  the 
same  in  all  cases,  the  method  of  its  use  is  described  under  screw- 
porte  (page  41). 

Elevator. — The  use  of  the  straight-shank  elevator  (Fig.  15) 
for  the  removal  of  the  root  of  this  tooth  is  indicated  where  decay 
is  extensive  labially,  but  a  firm  lingual  wall  remains.  This  con- 
dition is  very  common,  as  the  beginning  of  decay  near  the  gum 
margin  labially  on  the  central  incisor  is  of  frequent  occurrence. 
The  operation  in  such  case  is  performed  by  holding  the  handle 
of  the  elevator  high  in  the  palm  of  the  hand  and  grasping  it 
tightly,  passing  the  blade  between  the  lingual  wall  of  the  tooth 
and  the  gum  tissue  (Fig.  58).  A  steady  application  is  now  made, 
in  the  meantime  executing  a  slight  right-and-left  turning  move- 
ment while  tipping  the  handle  distally.  By  these  combined 
movements  the  point  of  the  instrument  is  forced  between  the  root 
and  the  process.  The  root  is  then  lifted  from  its  socket,  using 
the  elevator  as  a  lever  and  the  lingual  margin  of  the  socket  as 
its  fulcrum. 

Where  decay  is  so  extensive  that  only  a  small  amount  of  badly 
broken-down  tooth  structure  remains,  it  can  usually  be  removed 
with  a  Cryer  elevator  (Fig.  24),  and  is  accomplished  by  passing 
the  sharp  point  between  the  remaining  tissue  and  process  on  the 
lingual  side,  after  which  the  point  of  the  instrument  is  turned 
labially  and  the  root  extracted. 

Fracture. — A  fracture  of  this  tooth  while  operating  is  not  of 
such  frequent  occurrence  as  with  the  other  teeth  in  the  superior 
arch.  If  a  fracture  occurs,  and  a  reasonable  amount  of  structure 
remains  on  the  labial  and  lingual  sides,  the  forceps  are  reapplied. 
If  the  fracture,  however,  is  so  high  that  the  process  interferes 
with  the  usual  application,  the  alveolar  application  may  be  re- 
sorted to;  but  if  this  is  deemed  inadvisable,  the  screw-porte  or 


SUPERIOR  CENTRAL  INCISOR 


119 


Cryer  elevator  should  be  used.  When  using  the  Cryer  elevator 
for  these  cases,  the  chair  is  adjusted  as  low  as  possible.  The 
operator  should  take  a  position  to  the  right  side  of  the  patient 
and  apply  the  elevator  to  the  lingual  surface,  and,  when  the 
point  has  engaged  the  root,  exert  pressure  labially,  at  the  same 
time  turning  the  instrument  so  as  to  bring  the  point  downward, 
which  will  release  the  part  if  a  secure  hold  of  the  root  has  been 
obtained. 


Fig.  58. — Straight-shank  elevator  (Fig.  15)  applied  to  the  lingual  surface  of  a  superior 

centi'al  incisor  root. 


Chisel. — When  the  root  remaining  is  well  tunneled,  leaving 
only  a  thin  wall  hugging  the  process,  the  ordinary  enamel  chisel 
is  often  a  reliable  instrument  for  its  removal.  The  removal  is 
accomplished  by  separating  the  shell-like  portion  of  the  root 
from  the  process  at  two  or  more  points,  forcing  the  root  toward 
the  center,  and,  when  loosened,  removing  it  with  the  Derenberg 
tweezers. 

Reinforcing  Root. — In  a  case  of  very  extensive  decay,  or  where 
the  root  has  been  weakened  by  a  previous  removal  of  tooth  struc- 
ture from  the  root  canal  for  the  insertion  of  a  metal  post,  some 


120  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

operators  advocate  tilliug  tlie  root  caual  with  cement  or  amalgam 
to  increase  its  strength.  This  procedure  will  suffice  only  in  very 
rare  cases,  and,  as  a  rule,  is  not  good  practice. 

SUPERIOR  LATERAL  INCISOR. 

The  extraction  of  the  superior  lateral  incisor  is  a  little  more 
difficult  operation  than  the  extraction  of  the  central  incisor,  as 
the  neck  of  the  tooth  is  often  constricted  and  is  prone  to  fracture 
if  a  good  adjustment  of  the  forceps  is  not  obtained.  The  tooth 
is  more  frequently  displaced  than  the  central  incisor,  and  obtain- 
ing direct  access  in  such  case  is  an  important  matter.  Fig.  59 
show^s  the  various  types  of  superior  lateral  incisors,  and  atten- 
tion is  directed  to  the  occasional  distal  inclination  of  their  roots. 

Position  of  Patient  and  Operator. — The  position  of  the  patient 
in  the  chair  and  that  of  the  operator  is  as  described  for  extract- 
ing superior  teeth  (])age  O:]).  The  position  of  the  arm  of  the 
operator  and  the  arrangement  of  the  hand  and  fingers  are  as 
described  for  the  central  incisor  (page  108).  A  slight  variation 
of  the  position  of  the  head  of  the  patient  is  occasionally  made — 
the  face  being  turned  partially  toward  the  operator  where  un- 
usual resistance  occurs  during  the  extraction  movements. 

Forceps. — Standard  forceps  No.  1  (Fig.  1),  which  are  princi- 
pally employed  in  the  extraction  of  the  central  incisor,  are  also 
the  most  suitable  forceps  for  operating  on  the  lateral  incisor. 
The  variations  in  the  size  of  the  crown  and  frequent  malposition 
of  the  tooth,  however,  compel  changes  in  the  selection  of  forceps. 
Where  the  crown  is  of  small  size,  especially  if  it  is  of  the  peg- 
shape  type,  Standard  forceps  No.  5  (Fig.  6)  may  1ie  found  more 
suitable.  Where  the  tooth  is  displaced  lingually  or  labially, 
preference  should  be  given  to  Standard  special  A  or  special  B 
forceps  (Figs.  11,  12),  as  they  can  be  more  readily  adjusted. 
These  forceps  are  bayonet  shape,  but,  if  the  operator  is  careful, 
he  can  gauge  his  application  so  that  the  beaks  will  be  in  line 
with  the  axis  of  the  tooth.  The  shape  of  this  instrument  should 
not  be  of  any  great  hindrance  in  applying  the  extraction  move- 
ments, as  the  resistance  encountered  with  this  tooth  is  not  very 
great,  although  one  with  beaks  in  line  with  the  handle  is  prefer- 
able for  the  six  anterior  teeth  wherever  it  can  l)e  used.  When 
operating  under  a  general  anesthetic,  and  one  or  both  of  the 
bicuspid  teeth,  or  the  molar  roots,  are  to  be  extracted  in  addition 


^SUPERIOR  LATERAL  INCISOR 


121 


Fig.  59.— Types  of  superior  lateral  incisors.     The  first  row  shows  the  labial,  the  second 
row  the  lingual,  the  third  row  the  mesial,  and  the  fourth  row  the  distal  surface. 


122  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

to  this  tooth,  Standard  forceps  No.  2  (Fig.  2)  can  often  be 
applied  with  good  results. 

Order  of  Extraction. — As  previously  stated  (page  111),  the 
extraction  of  the  central  incisor  precedes  that  of  the  lateral 
when  both  of  these  teeth  are  to  be  removed.  If  the  cuspid  is 
also  to  be  removed,  the  order  should  continue  and  the  lateral  be 
extracted  before  the  cuspid.  This  order  should  always  be  fol- 
lowed unless  contraindicated  by  untoward  conditions,  as  the 
lateral  incisor  is  usually  not  so  difficult  to  dislodge  from  its 
socket  as  the  cuspid.  The  order  of  extraction  mentioned  allows 
a  freer  application  of  the  beaks  of  the  forceps  to  the  cuspid,  and 
in  some  cases  the  extraction  of  the  lateral  weakens  the  septum  of 
alveolus  between  the  lateral  and  cuspid,  which  materially  lessens 
the  resistance  of  the  cuspid  to  dislodgment. 

Application  of  Forceps. — The  api')lication  of  the  forceps  to  the 
neck  of  this  tooth  is  made  in  a  similar  manner  to  that  described 
for  the  central  incisor.  The  beaks  should,  however,  be  sent  a 
little  further  up  on  the  neck  of  the  tooth  on  the  lingual  surface 
than  is  done  in  the  application  to  the  central  incisor.  The  ad- 
justment of  the  beaks  of  the  forceps  to  this  part  of  the  tooth 
should  be  accurate,  and  so  made  that  it  covers  the  greatest  pos- 
sible amount  of  surface.  In  sending  the  beaks  up  under  the 
free  margin  of  the  gum,  the  operator  must  progress  slowly,  so 
as  to  carefully  gauge  the  required  amount  of  force,  as  the  process 
surrounding  this  tooth  is  constricted,  and  there  is  danger  of  forc- 
ing the  forceps  too  high  and  unnecessarily  destroying  healthy 
tissue. 

Alveolar  Application  of  Forceps. — An  alveolar  application 
can  be  more  readily  made  on  this  tooth  than  on  the  central  on 
account  of  the  depression  of  the  process  in  this  region.  As 
decay  above  the  gingival  line  is  of  frequent  occurrence  and  the 
small  neck  closely  approximates  the  alveolar  border,  either  of 
which  increases  the  liability  to  fracture,  alveolar  application 
becomes  necessary  more  often  than  with  the  central  incisor.  The 
technic  is  similar  to  that  for  operating  on  the  central,  but 
greater  care  must  be  exercised  to  prevent  the  forceps  from 
slipping  too  far  over  the  alveolar  border  into  the  incisal  fossa 
and  causing  an  ugly  wound. 

Extraction  Movements. — The  extraction  movements  are  dif- 
ferent from  those  applied  to  the  central  incisor.    Eotatory  move- 


SUPERIOR  LATERAL  INCISOR 


D 


Fig.  60.— Extraction  movements  for  superior  lateral  incisor.  A,  forceps  (Standard 
No  1)  applied;  B,  first  movement  to  the  lingual  side;  C,  reversed  movement  to  the 
labial  side;  D,  tractile  movement  downward  in  line  with  the  ongmal  position  ot 
the   tooth. 


124  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

ments  must  not  be  attempted  here,  as  the  root  of  this  tooth  is 
flattened  on  its  mesial  and  distal  surfaces.  If  the  application 
of  the  forceps  (Fig.  60,  A)  has  not  loosened  the  tooth  in  its 
socket,  the  next  step  is  to  direct  the  first  extraction  movement 
to  the  lingual  side  (Fig.  60,  B).  Directing  the  forceps  to  the 
lingual  side  should  not  be  attempted  too  forcibly,  as  this  move- 
ment is  made  principally  for  the  purpose  of  sending  the  beak 
adjusted  to  the  lingual  side  further  up  on  the  neck  of  the  tooth, 
so  that  it  may  be  more  securely  placed.  This  movement  is  fol- 
lowed by  l)ringing  the  tooth  with  the  same  amount  of  force 
to  the  labial  side  (Fig.  60,  C).  The  alveolar  process,  being  the 
weaker  on  this  side,  allows  the  tooth  to  be  more  readily  forced  in 
this  direction,  and  considerable  space  is  gained.  These  two 
movements  will  in  most  cases  loosen  the  tooth  from  its  attach- 
ment, and,  if  not,  they  are  repeated  until  it  is  loosened,  when  it 
is  brought  back  to  its  original  position  and  the  extraction  com- 
pleted by  a  downward  tractile  movement  applied  in  line  with 
the  axis  of  the  tooth  (Fig  60,  D). 

The  operator  should  ])ear  in  mind  that  the  neck  of  this  tooth 
is  fre(]uently  constricted,  which  necessarily  causes  weakness  at 
this  point,  and  he  should  gauge  the  force  of  the  extraction  move- 
ments accordingly,  lest  fracture  occur.  Special  caution  should 
be  observed  where  the  central  and  cusjiid  are  in  position,  or 
where  the  tooth  is  partially  displaced  lingually,  to  avoid  injur- 
ing the  enamel  of  these  teeth  with  the  forceps. 

Displacement — Complete  Li uf/ual.— Where  the  tooth  is  com- 
pletely dis})laced  to  the  lingual  side  of  the  arch,  and  the  space 
where  it  should  normally  be  situated  is  closed,  lingual  and  labial 
application  is  often  impossible.  Standard  forceps  No.  1  should 
be  selected,  and  the  beaks  are  applied  to  the  mesial  and  distal 
surfaces  of  the  tooth  (Fig.  61).  In  adjusting  the  forceps  to  these 
surfaces,  care  should  be  taken  that  the  beaks  grasp  as  much  as 
possible  of  the  tooth  structure.  If  the  distal  surface  of  the  tooth 
is  in  close  contact  with  the  cuspid.  Standard  forceps  No.  5  can 
often  l)e  advantageously  used.  In  making  the  application  and 
during  the  extraction  movements  the  operator  should  be  careful 
not  to  injure  the  enamel  of  adjacent  teeth  by  liringing  the  beaks 
too  forcibly  against  them. 

When  the  forceps  have  been  a|)plied,  the  first  extraction  move- 
ment is  to  the  lingual  side,  and  is  made  with  as  much  force  as 


SUPERIOR  LATERAL  INCISOR 


125 


possible  without  caiisini>-  fracture.  Jf  this  luoveineiit  does  not 
loosen  the  tooth  from  its  attachment,  a  slightly  swaying  move- 
ment in  the  most  favorable  direction  is  executed,  followed  by 
again  bringing  it  to  the  lingual  side.  When  the  latter  move- 
ments have  been  made  and  some  sjiace  has  been  secured,  the 
tooth  is  brought  to  the  labial  side  as  far  as  the  distance  created 
by  the  lingual  movement  will  permit,  when,  with  a  degree  of 
force  downward  direct  in  line  with  its  original  position,  the 
tooth  is  delivered  from  its  socket. 

If  the  execution  of  these  movements,  however,  fails  to  dislodge 


Fig.   61. — Mesial  and  distal  application  of  forceps  (Standard  No.  1)  to  a  superior  lateral 
incisor  completely  displaced  to  the  lingual  side  of  the  arch. 


the  tooth,  they  must  be  repeated  until  extraction  is  finally  ac- 
complished, and  on  each  repetition  of  the  movement  advantage 
should  be  taken  of  any  space  that  may  have  been  gained,  which 
is  done  by  making  a  higher  adjustment  of  the  forceps  on  the 
tooth. 

Complete  Labial. — Where  this  tooth  is  displaced  completely 
to  the  labial  side  of  the  arch,  the  application  of  the  forceps  will 
be  the  same  as  where  it  is  displaced  completely  to  the  lingual 
side,  but  the  application  should  be  made  with  some  degree  of 
force,  as  a  complete  delivery  of  the  tooth  on  the  first  application 


126  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

may  often  be  accomplislied.  If  such  delivery  cannot  be  made, 
the  first  movement  should  be  labially,  then  slightly  lingually, 
and  repeated  until  the  tooth  is  loosened,  when  it  is  brought 
straight  from  its  socket. 

Extraction  of  laterals  in  labial  occlusion  is  usually  not  diffi- 
cult, as  the  process  external  to  the  root  is  not  heavy. 

Partial  Lingual. — In  a  partial  lingual  displacement,  Standard 
forceps  No.  1  are  to  be  preferred,  but,  if  space  will  not  permit 
their  ai^plication,  the  operator  should  choose  between  Standard 
forceps  No.  5  and  Standard  special  A  or  special  B  forceps.  If 
the  crown  is  small  and  the  space  limited.  Standard  forceps  No. 
5  should  be  used.  If  the  tooth  is  large,  and  space  between  the 
approximating  teeth  is  sufficient  for  one  narrow  and  one  broad 
beak,  one  of  the  Standard  special  forcejDS  are  selected,  in  which 
case  the  narrow  beak  is  first  applied  to  the  narrow  space  on  the 
labial  side.  The  first  extraction  movement  is  made  to  the  lin- 
gual side  with  sufficient  force  to  loosen  the  tooth  if  possible,  care 
being  taken  to  avoid  a  fracture.  The  beaks  are  then  sent  further 
on  the  tooth,  when  it  is  brought  slightly  to  the  labial  side  and 
then  carried  forcibly  to  the  lingual  side,  followed  with  a  tractile 
movement  downward,  and  the  tooth  delivered  from  its  socket. 

Partial  Labial. — Where  the  tooth  is  partially  displaced  to  the 
labial  side,  the  same  forceps  and  technic  are  used  as  described 
where  it  is  displaced  lingually,  and  the  principal  movement  is  to- 
the  labial  side. 

Botated. — Where  the  tooth  is  partially  or  completely  rotated 
in  its  socket,  the  selection  and  application  of  forceps  and  the 
extraction  movements  are  similar  to  those  employed  when  oper- 
ating on  the  tooth  in  normal  occlusion. 

Impaction. — This  tooth,  like  the  central  incisor,  is  seldom  im- 
pacted, and,  if  in  that  condition,  it  is  rarely  extracted,  as  such 
case  is  usually  referred  to  the  orthodontist  for  correction. 

Extensive  Caries. — The  lateral  incisor  is  subject  to  decay 
above  the  gingival  line — both  labially  and  lingually,  especially 
lingually — as  the  enamel  coverings  in  the  lingual  pit  and  the 
linguo-gingival  groove  are  often  imperfect.  The  application  of 
the  forceps  and  the  extraction  movements,  eliminating  any 
attempt  at  rotatory  movements,  are  the  same  as  for  the  central 
incisor  in  a  like  condition,  and  the  same  care  in  the  application 
of  the  forceps  and  force  of  the  movements  should  be  exercised 


SUPERIOR  LATERAL  INCISOR  127 

as  with  the  central  incisor.  Where  the  tooth  is  attacked  by 
caries  on  the  mesial  or  distal  surface,  or  both  surfaces,  and  the 
decay  is  very  extensive,  it  should  be  treated  as  if  it  were  a  root, 
and  the  technic  of  extraction  is  the  same  as  for  a  lateral  incisor 
root. 

Lateral  Incisor  Root. — The  extent  of  decay  and  the  strongest 
and  weakest  parts  of  the  root  govern  the  selection  of  forceps  and 
the  amount  of  pressure  that  may  be  judiciously  used  in  their 
application.  Care  should  be  taken  when  operating  on  the  root 
of  this  tooth  on  account  of  its  proneness  to  fracture.  Where  a 
fairly  sound  structure  is  found  at  the  neck,  Standard  forceps 
No.  1  should  be  applied,  and  the  extraction  movements  are  the 
same  as  where  the  crown  is  intact.  Where  the  root  is  small, 
Standard  forceps  No.  5  should  be  used,  and  are  applied  well  up 
on  the  root  to  secure  good  adjustment.  Where  the  forceps  cannot 
be  applied,  extraction  may  be  performed  with  the  elevator  as  de- 
scribed on  page  128,  and  for  the  removal  of  a  deep-seated  root 
the  procedure  may  be  as  described  below  under  root  fractured. 

Root  Covered  by  Gum  Tissue. — Frequently  the  root  of  this 
tooth  is  partially  or  completely  covered  by  gum  tissue,  and  in 
such  case  the  application  of  the  forceps  is  the  same  as  for  the 
central  incisor  in  a  like  condition  (page  116).  Marginal  alveolar 
caries  is  nearlj"  alwaj^s  present  when  the  root  is  in  this  condition, 
and,  when  present,  a  freer  application  of  the  forceps  can  be  made 
than  where  the  process  is  normal.  Application  of  the  forceps 
is  governed  by  the  operator's  sense  of  touch,  which  will  convey 
to  him  the  difference  between  sound  and  carious  alveolar  struc- 
ture. After  the  application,  the  extraction  movements  are  exe- 
cuted as  outlined  for  this  tooth  if  the  pressure  of  the  application 
has  failed  to  release  it. 

Root  Fractured. — The  root  of  a  lateral  incisor  frequently 
tapers  to  a  very  fine  point,  which  is  usually  curved  distally.  The 
root  is  easily  fractured  at  the  point  of  greatest  deflection,  and, 
when  fractured  at  this  point,  the  extraction  of  the  remaining 
tip  becomes  a  very  delicate  operation.  It  is  usually  beyond  the 
reach  of  forceps  or  elevator,  and  may  be  left  in  situ  if  it  is 
thought  that  it  will  not  cause  any  further  disturbance;  but,  if  a 
pathologic  condition  is  present  at  its  apex,  removal  may  be  a 
necessity.  The  fragment  can  usually  be  cut  out  with  a  small 
rose  bur  with  less  injury  to  the  tissue  than  if  its  extraction  is 


128  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

attempted  with  either  forceps  or  elevator.  Wliere  the  part  re- 
maining is  rather  large,  and  the  alveolus  is  projecting  sufficiently 
to  interfere  with  the  application  of  the  beaks  of  the  forceps  or 
the  blade  of  an  elevator,  the  method  of  operating  is  to  cut  away 
enough  process  with  a  sharjj  bur  to  allow  the  forceps  to  be  ad- 
justed or  the  blade  of  the  elevator  to  be  applied  to  the  root.  If 
the  root  is  large  enough,  the  screw-porte  may  be  used  instead. 

Root  Wedged. — Where  the  approximal  space  is  closed  over 
the  root  by  the  central  incisor  and  cuspid,  and  the  root  is  not 
tirjnly  attached,  the  straight-shank  elevator  (Fig.  15)  may  be 
employed,  as  described  for  the  central  incisor,  to  dislodge  it 
(page  118).  If  the  root  is  firmly  imbedded,  it  is  detached  from 
its  socket  with  the  Cryer  elevator  (Fig.  24),  and,  if  necessary, 
the  straight-shank  elevator  is  then  applied  to  push  it  further 
toward  the  labial  side,  where  it  can  be  reached  with  the  forceps 
or  Derenberg  tweezers.  Where  the  root  is  very  frail,  and  the 
use  of  an  elevator  is  impossible,  the  chisel  will  serve  to  separate 
it  in  sections,  and  the  parts  are  removed  with  the  Derenberg 
tweezers. 

Screw-Porte. — The  application  of  the  screw-porte  is  limited 
more  in  the  case  of  the  lateral  incisor  than  that  of  the  central, 
as  the  root  canal  of  the  former  is  not  so  large  and  does  not  re- 
ceive the  screw-porte  so  readily.  Where  the  root  is  deep-seated, 
and  the  alveolus  interferes  with  the  adjustment  of  the  forceps  or 
the  application  of  the  elevator,  sometimes  extraction  can  be 
successfully  accomplished  by  selecting  a  screw-porte  with  a  fine 
point. 

Elevator. — The  use  of  the  straight-shank  elevator  as  described 
for  central  incisor  (page  118)  is  not  practicable  when  the  root 
of  this  tooth  is  of  considerable  size,  as  the  elevator  can  be  used 
successfully  only  where  the  root  is  short  and  not  firmly  attached. 
When  the  elevator  is  used,  it  should  be  applied  to  the  lingual 
side  and  given  a  pushing  movement  to  the  labial  side  until  the 
root  is  entirely  dislodged,  or  loosened  sufficiently  to  be  removed 
with  the  Derenberg  tweezers.  Where  there  is  a  strong  wall 
on  the  distal  side  and  decay  has  undermined  the  other  part  of 
the  root,  the  Cryer  elevator  can  be  advantageously  applied  in 
some  cases  to  the  disto-lingual  side,  using  the  cuspid  as  a  ful- 
crum. When  the  elevator  is  applied,  the  blade  is  sent  as  far 
down  as  possible  on  this  side  of  the  root  and  turned,  engaging 


SUPERIOR  CUSPID  129 

the  root  with  the  point  of  the  elevator  and  lifting  it  from  its 
socket. 

SUPERIOR  CUSPID. 

The  extraction  of  the  superior  cuspid  is  usually  attended  by 
considerable  resistance,  depending  on  the  size  of  the  tooth  and 
the  strength  of  the  alveolar  process.  Fig.  62  shows  the  various 
types  of  superior  cuspids,  some  of  them  presenting  the  occa- 
sional distal  inclination  of  their  roots. 

Position  of  Patient  and  Operator. — The  position  of  the  patient 
in  the  chair  and  that  of  the  operator  is  as  described  for  extract- 
ing superior  teeth  (page  93).  AVhen  operating  on  the  left  side  of 
the  arch,  the  head  of  the  patient  is  turned  toward  the  operator. 
The  left  arm  of  the  operator  is  placed  around  the  head  of  the 
patient,  with  the  palm  of  the  hand  over  the  left  cheek;  the  index 
finger  raises  the  upper  lip,  exposing  the  field  of  operation;  the 
second  finger  is  placed  on  the  labial  surface  of  the  inferior  teeth; 
the  third  and  fourth  fingers  are  placed  against  the  lower  part  of 
the  cheek  (Fig.  63).  This  position  gives  the  operator  an  unob- 
structed view  and  also  supports  the  patient's  head. 

When  operating  on  the  right  side  of  the  arch,  the  head  of  the 
patient  is  placed  straight  in  the  head-rest  or  turned  slightly 
toward  the  left.  The  left  arm  of  the  operator  and  the  palm  of 
the  hand  are  arranged  in  the  same  manner  as  when  operating  on 
the  left  side  of  the  arch,  but  the  fingers  are  brought  toward  the 
right  cuspid  (Fig.  64).  Changing  from  one  position  to  the  other 
can  be  quickly  done,  and,  when  both  cuspids  are  to  be  extracted, 
the  left  one  is  removed  first. 

Forceps.- — Standard  forceps  No.  1  (Fig.  1),  which  are  usually 
employed  in  the  extraction  of  the  central  and  lateral  incisors,  are 
also  the  most  suitable  forceps  for  the  removal  of  the  cuspid.  A 
number  of  heavy-handled  forceps  are  manufactured  especially 
for  the  extraction  of  this  tooth,  and  some  of  these  forceps  are 
practical,  but  the  author  is  of  the  opinion  that  better  execution 
can  be  had  by  the  operator  accustoming  himself  to  the  use  of  the 
one  forceps,  so  that  his  sense  of  touch  will  readily  convey  to  him 
the  extent  to  which  the  instrument  accommodates  itself  to  the 
condition  presented.  Standard  forceps  No.  1  have  been  found  to 
possess  suflBcient  strength  to  meet  any  requirement.  Where  the 
tooth  is  displaced,  Standard  special  A  and  special  B  forceps  are 


130  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

employed,  and  used  in  the  same  manner  as  for  centrals  and  lat- 
erals in  a  like  position. 

Order  of  Extraction. — Where  the  teeth  adjacent  to  the  superior 
cuspid  are  also  to  be  removed,  their  removal,  in  order  to  reduce 
the  amount  of  resistance  that  is  nearly  always  encountered  in  the 
extraction  of  this  tooth,  should  precede  that  of  the  cuspid.  This 
procedure  will  afford  a  better  adjustment  of  the  beaks  of  the  for- 
ceps to  the  latter  tooth. 

Application  of  Forceps. — The  operator  should  bear  in  mind 
that  the  head  of  the  patient  is  turned  to  the  right,  or  possibly 
slightly  to  the  left,  and  note,  when  a])plying  the  forceps  to  the 
cuspid,  that  the  application  is  made  in  line  with  its  axis.  The 
order  of  first  adjusting  one  beak  to  the  lingual  surface  of  the 
tooth  and  then  the  opposing  one  to  the  labial  surface  should  be 
followed,  as  when  making  application  to  the  incisors.  As  the 
cuspid  possesses  a  long  and  heavy  root,  surrounded  by  dense, 
heavy  process,  with  a  firm  alveolar  ridge,  much  greater  pressure 
may  be  exercised  in  sending  the  beaks  of  the  forceps  on  this  tooth 
than  on  any  other.  This  is  done  by  placing  the  palm  of  the  hand 
against  the  swell-end  of  tlie^  handle  of  the  forceps  as  soon  as 
adjustment  has  been  had,  and  exerting  a  firm,  steady  pressure 
upward.  Special  care  must  be  taken  in  adjusting  the  beak  to 
the  lingual  surface,  as  there  is  little  constriction  of  this  tooth  at 
its  neck,  and,  the  linguo-gingival  ridge  being  very  near  the 
margin  of  the  process,  there  is  a  tendency  for  this  beak  of  the 
forceps  to  slip  from  its  position. 

When  the  lateral  incisor  and  first  bicuspid  are  missing  or 
have  just  been  extracted,  a  better  application  can  often  be  made 
by  adjusting  the  forceps  to  the  mesial  and  distal  surfaces  of  the 
tooth  (Fig.  65).  The  advantage  of  this  application  is  a  better 
adaptation  of  the  beaks  of  the  forceps,  owing  to  the  flattened 
surfaces  of  the  tooth  at  its  neck  on  these  sides.  The  firmer  grip 
thus  secured  enables  the  operator  to  make  the  extraction  move- 
ments with  greater  freedom  of  motion,  and  lessens  the  danger  of 
fracturing  the  process. 

Alveolar  Application  of  Forceps. — Alveolar  application  to  the 
cuspid  is  not  practicable,  and  should  not  be  attempted  unless 
the  jDrocess  has  been  weakened  by  caries.  If  it  is  necessary  to 
apply  the  beaks  of  the  forceps  above  the  margins  of  the  process 
to  obtain  a  secure  adjustment  to  the  tooth,  it  is  advisable  to 


SUPERIOR  CUSPID 


131 


Fig.   62. — Types   of  .superior  cuspid.s.     Tiie   flr.st   row    allows   llie   labial,    the    second   row 
the  lingual,   the  third  row  the  mesial,  and  the  fourth  row  the  distal  surface. 


132 


EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 


remove  a  part  of  the  process  with  a  cross-cut  bur  before  attempt- 
ing the  application.  This  removal  of  the  marginal  ridge  of  the 
process  with  a  bur  is  preferable  to  endangering  the  external 
plate  by  the  heavy  force  which  is  sometimes  required  to  loosen 


Fig.  63. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  a  superior  cuspid  on  the  left  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.  1)   to  the  superior  left  cuspid. 

the  tooth  from  its  attachment.  Where  the  posterior  teeth  have 
been  lost  for  a  considerable  time,  the  process  in  the  region  of  the 
cuspids  is  usually  very  thick  and  dense  in  order  that  these  teeth 
may  bear  the  increased  pressure  constantly  exerted  on  them. 
Examination  should  be  made  for  the  probable  existence  of  this 


SUPERIOR  CUSPID 


133 


condition,  and,  if  present,  there  should  be  no  hesitation  to  re- 
move part  of  the  process  before  attempting  to  adjust  the  forceps. 
Extraction  Movements.— With  Standard  forceps  No.  1  applied 
to  this  tooth  (Fig.  66,  A),  the  first  movement,  with  a  force  gov- 


Fig.  G4.-Position  of  the  operator's  hands.and  disposition  of  the  f^^evsjhen^wiyn^S 
forceps  to  a  superior  cuspid  on  the  right  side  of  the  aich.  Ilhistration  snows  inc 
application  of  forceps   (Standard  No.    1)    to  the    superior  right   cuspid. 

erned  by  the  size  and  strength  of  the  root  and  the  resistance 
offered,  is  to  bring  the  tooth  to  the  labial  side  (Fig.  66,  B),  this 
being  thd^Kiirection  of  least  resistance,  and  then,  reversing  the 
movement  with  an  equal  amount  of  force,  the  tooth  is  forced 
lingually  (Fig.  66,  C).     These  two  movements,  carefully  exe- 


134  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

cuted,  should  enable  the  operator  to  fairly  judge  the  strength 
of  the  tooth  and  the  resistance  to  he  overcome.  This  knowledge 
having  been  gained,  these  movements  are  repeated  with  in- 
creased stress  in  each  direction  (Fig.  66,  D,  E)  nntil  the  attach- 
ment of  the  tooth  has  been  broken  up,  when  it  is  brought  back 
to  its  original  position  and  removed  from  its  socket  with  a  trac- 
tile movement  downward  in  line  with  its  original  position 
(Fig.  QQ,F). 

If  the  technic  described  above  fails  to  loosen  the  tooth  from 
its  attachment,  conditions  other  than  normal  may  be  suspected. 


Fig.  65. — Me.sial  and  distal  application  of  forceps  (Standard  No.   1)   to  a  superior  light 
cuspid  when  both  adjacent  teeth  have  been  extracted  in  advance  of  the  cu.spid. 

A  condition  frequently  exists  in  which  there  is  partial  or  almost 
complete  loss  of  the  peridental  membrane,  due  to  a  thickening  of 
the  pericementum.  AVhere  this  condition  exists,  the  adhesion 
of  the  root  to  the  process  is  very  tenacious,  l)eing  at  times  so 
complete  that  parts  of  the  process  will  adhere  to  the  tooth  on 
its  removal  without  disturbing  the  x)lates  of  the  process  itself. 
If  this  condition  is  present,  the  adhesion  should  be  broken  up 
by  a  very  slight  rotatory  movement  of  the  tooth  from  the  labial 
to  the  mesial  side,  but  it  should  l)e  borne  in  mind  that,  as  the  root 
is  flattened  in  its  mesio-distal  diameter,  the  reverse  rotatory 
movement  should  not  be  attempted,  as  it  will  probably  cause  a 


SUPERIOR  CUSPID 


135 


B 


D 


E 


F 


Fig.  66. — Extraction  movements  for  superior  cuspid.     A,   forceps   (Standard  No.   1)  ap 
plied;   B,   first  movement   to   the   labial   side;    C,    reversed  movement   to    the   lingual 
side;  D,  E,  movements  B  and  C  more  forcibly  repeated;  F,  tractile  movement  down- 
ward in  line  with  the  original  position  of  the  tooth. 


136  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

fracture  of  the  root  near  the  apex  if  this  part  is  curved  distally. 
If  this  slight  rotatory  movement,  combined  with  the  other  move- 
ments described  and  illustrated,  fails  to  break  up  the  attachment 
of  the  tooth,  the  operator  should  remove  the  margin  of  the 
process  about  the  tooth  with  a  cross-cut  bur  before  proceeding 
with  the  extraction  movements. 

Displacement.- — Where  this  tooth  is  displaced  to  the  lingual 
or  labial  side  of  the  arch,  it  should  not,  as  a  rule,  be  extracted 
for  the  purpose  of  correcting  the  defect.  Such  a  condition  should 
always  be  referred  to  the  orthodontist  for  treatment,  as  the  facial 
expression  and  contour  of  the  arch  depend  very  much  on  this 
tooth.  Occasionally  in  advanced  age,  when  regulation  is  no 
longer  expedient,  extraction  may  be  indicated. 

Comjilete  Linynal. — Where  this  tooth  is  in  complete  lingual 
displacement,  and  application  of  the  forceps  to  the  labial  and 
lingual  surfaces  is  possible,  the  forceps  should  be  applied  in  that 
manner.  If,  however,  such  application  is  impossible,  a  mesio- 
distal  application  may  be  made,  as  described  and  illustrated  in 
the  case  of  lateral  incisor  (page  124).  AVhen  application  has  been 
made  by  either  of  the  above  methods,  the  first  and  principal 
movement  is  to  the  lingual  side,  with  such  labial  movement  as 
the  location  of  the  tooth  will  permit,  and,  as  space  is  gained  by 
these  movements,  a  reapplication  should  be  made  so  as  to  secure 
as  firm  grasp  as  possible  to  the  tooth.  When  the  tooth  has  been 
loosened,  it  is  carried  from  its  socket  in  the  usual  direction. 

Where  the  tooth  is  only  partially  erupted,  and  there  is  process 
still  covering  any  portion  of  the  crown,  an  incision  is  made  in 
the  soft  tissues  to  fully  expose  the  crown,  when  a  sufficient  quan- 
tity of  the  bony  structure  is  removed  with  a  bur  to  fully  expose 
the  crown,  after  which  the  forceps  are  applied  and  the  tooth 
removed.  Frequently  the  Cryer  elevator  (Fig.  24)  can  be  used 
to  advantage  in  loosening  the  tooth  before  applying  the  forceps. 
When  the  elevator  is  used,  the  first  bicuspid  or  the  process  serves 
as  a  fulcrum,  a  very  slight  turning  movement  is  executed  to 
engage  the  tooth,  and,  when  engaged,  a  further  turn  of  the  point 
of  the  elevator  toward  the  tooth  should  break  up  its  attachment. 

Complete  LahiaJ. — Complete  labial  displacement  is  common 
with  the  superior  cuspid,  and,  in  addition  to  this  displacement, 
its  position  varies  greatly  in  its  relation  to  the  lateral  incisor 
and  to  the  first  bicuspid.     In  infra-occlusion  it  may  appear  at 


SUPERIOR  CUSPID  137 

any  point  on  the  gum  from  the  deflection  of  the  lip  above  to  the 
normal  gingival  margin  below.  Standard  forceps  No.  1  (Fig.  1) 
are  used  for  its  extraction,  and,  where  possible,  the  labio- 
lingual  application  is  made,  but,  when  this  cannot  be  obtained, 
the  forceps  are  applied  to  the  mesial  and  distal  surfaces.  Fre- 
quently the  simple  application  of  the  forceps  is  sufficient  to 
loosen  the  tooth  from  its  attachment,  as  the  process  surround- 
ing its  root  is  usually  not  heavy.  If  the  application  does  not 
loosen  the  tooth,  the  first  and  principal  extraction  movement  is 
labially,  followed  by  such,  lingual  movement  as  space  will  permit, 
and,  if  resistance  is  still  encountered,  the  slight  rotatory  move- 
ment as  described  under  extraction  movements  for  this  tooth 
(page  134)  may  be  applied.  Occasionally  it  is  necessary  to  re- 
apply the  forceps  after  the  tooth  has  been  loosened,  and  continue 
the  extraction  movements,  before  the  tooth  can  be  brought  from 
its  socket. 

In  all  cases  secure  adjustment  must  be  had,  as  an  attempt  to 
apply  the  extraction  movements  while  grasping  only  a  part  of 
the  crown  will,  as  a  rule,  result  in  the  forceps  slipping  from  the 
tooth.  If  eruption  is  incomplete,  sufficient  process  around  the 
tooth  should  be  removed  with  a  cross-cut  bur  to  allow  the  proper 
application  of  the  forceps.  Occasionally  the  Cryer  elevator 
(Fig.  24),  applied  to  the  distal  side  of  the  crown,  may  be  advan- 
tageously used  to  loosen  the  tooth  preliminary  to  the  application 
of  the  forceps.  Complete  extraction  should  not,  however,  be 
attempted  with  the  elevator. 

Palatial  Lingual  or  Lahial. — Where  this  tooth  is  displaced 
partially  to  the  lingual  or  labial  side  of  the  arch,  and  the  ap- 
proximating space  between  the  lateral  incisor  and  the  first 
bicuspid  is  large  enough,  Standard  forceps  No.  1  should  be  used 
for  its  removal.  Where  the  space  will  not  permit  the  beaks  of 
these  forceps  to  be  introduced.  Standard  special  A  or  special  B 
forceps  are  employed.  The  application  of  the  forceps  and  the 
extraction  movements  do  not  differ  materially  from  the  teclmic 
in  the  case  of  lateral  incisor,  applying  such  increased  force  as 
the  greater  strength  of  the  tooth  and  its  attachment  may  justify. 

Impaction. — To  define  the  ordinary  meaning  of  the  word 
"impacted"  is  comparatively  easy,  but  the  term  in  its  applica- 
tion in  practice  is  often  ambiguous.  Owing  to  the  diiference  of 
opinion  generally  prevailing  as  to  what  is  an  impacted  tooth,  the 


138  EXTRACTION  TECHNIG  OF  SUPERIOR  TEETH 

author  deems  it  advisable  to  state  what  should  and  what  should 
not  be  considered  an  impacted  tooth  from  the  standpoint  of  an 
exodontist. 

Impacted  teeth  are  divided  into  two  general  classes:  First — 
an  unerupted  or  partially  erupted  tooth  that  causes  no  trouble 
may  not  be  classed  as  an  impacted  tooth  while  in  this  condition, 
but,  should  the  process  of  eruption  reestablish  itself,  and  suffi- 
cient inflammation  arise  to  produce  greater  or  less  local  or  sys- 
temic disturbance,  and  further  eruption  is  prevented  by  another 
tooth,  alveolar  process,  or  gum  tissue,  the  tooth  immediately 
becomes  an  impacted  one.  Second — an  erupted  tooth,  partially 
or  completely,  that  cannot  be  removed  from  its  socket  in  line 
with  its  axis  without  the  disturbance  of  another  tooth  or  the 
removal  of  alveolar  process,  is  also  an  impacted  one,  whether  it 
is  or  is  not  in  process  of  further  eruption. 

Where  the  superior  cuspid  is  impacted,  and  located  either  to 
the  labial  or  lingual  side  of  the  arch,  if  there  is  sufficient  erup- 
tion for  the  application  of  the  forceps  or  the  elevator,  the  usual 
procedure  for  extracting  the  cuspid  in  labial  or  lingual  occlu- 
sion applies.  If  the  eruption  is  not  sufficient  to  obtain  a  clear 
outline  of  the  tooth,  the  operator  should  not  proceed  until  such 
an  outline  has  been  established.  In  such  case  resort  should  be 
had  to  radiography,  as  a  good  radiograph  will  enable  him  to 
clearly  diagnose  the  case.  The  diagnosis  having  been  completed, 
an  incision  is  made  in  the  soft  tissue  over  the  crown  of  the  tooth, 
and  sufficient  amount  of  alveolar  process  is  removed  to  fully 
expose  the  crown,  when  the  forceps  may  l)e  applied  and  the 
tooth  removed  from  its  position.  The  Cryer  elevator  may  often 
be  used  preliminary  to  the  application  of  forceps. 

Caries. — For  the  removal  of  a  supenor  cuspid  attacked  by 
caries  above  the  gingival  line,  either  labially  or  lingually,  the 
technic  is  practically  the  same  as  for  the  central  incisor  in  a 
like  condition,  except  that  rotatory  movements  should  be  at- 
tem])ted  only  as  explained  in  extraction  movements  applicable  to 
the  cuspid,  and  that  alveolar  application  of  the  forceps  should 
be  attempted  only  where  marginal  caries  of  the  process  is 
present. 

Where  the  tooth  is  attacked  by  decay  mesially  or  distally,  or 
both,  and  the  decay  is  not  extensive,  the  application  of  the  for- 
ceps and  the  extraction  movements  should  be  executed  as  though 


SUPERIOR  CUSPID  13!> 

the  tooth  were  not  affected;  but  if  the  decay  is  extensive,  the 
same  technic  as  for  extracting  roots  is  followed. 

Cuspid  Root. — The  root  of  a  badly  broken-down  superior 
cuspid  is,  other  conditions  being  equal,  more  difficult  to  remove 
than  that  of  any  other  anterior  tooth.  Standard  forceps  No.  1 
(Fig.  1)  are  usually  used  for  its  removal,  but,  where  better 
adaptation  to  the  root  can  be  secured  with  Standard  forceps 
No.  2  (Fig.  2),  recourse  may  be  had  to  them.  In  making  the 
application,  owing  to  the  increased  lal)io-lingual  diameter  of  the 
tooth,  care  should  l^e  taken  to  open  the  forceps  sufficiently  wide 
to  embrace  the  entire  circumference  of  the  root.  With  the  for- 
ceps adjusted,  the  usual  movements  applicable  to  this  tooth  are 
employed,  but  no  tractile  movement  should  be  attempted  until 
the  root  has  been  loosened.  At  times  a  good  method  of  pro- 
cedure is  a  repeated  application  of  the  beaks  after  each  labio- 
lingual  movement,  w^hich  forces  one  or  both  beaks  of  the  forceps 
between  the  x)eriphery  of  the  root  and  the  process,  and  loosens 
the  tooth  by  the  wedge-like  force  thus  exerted. 

Where  the  root  is  deeply  seated  and  covered  l)y  the  gum  tissue, 
the  same  technic  a])plies  as  descril)ed  and  illustrated  in  the  case 
of  centrals  (page  116.)  In  removing  small  tips  of  the  root,  it 
may  be  necessary  to  resort  to  the  dental  engine  and  the  round 
bur,  and  in  roots  well  hollowed  out  the  enamel  chisel  is  some- 
times employed.  In  the  latter  case,  however,  if  the  walls  re- 
maining possess  sufficient  strength,  the  screw-porte  is  a  better 
instrument  for  extraction. 

The  use  of  the  straight-shank  elevator  (Fig.  15),  as  sometimes 
employed  in  the  removal  of  the  roots  of  the  central  incisor,  is 
not  usually  practica1)le  with  this  tooth,  owing  to  the  increased 
resistance  to  be  overcome.  The  Cryer  elevator  (Fig.  24)  can. 
however,  often  be  used  to  advantage,  and,  when  used,  applica- 
tion is  made  at  the  disto-lingual  side  of  the  root,  using  the  first 
bicuspid  and  the  alveolar  process  in  this  region  as  the  fulcrum. 
AVhen  this  elevator  is  forced  well  up  and  turned  sufficiently 
to  engage  the  root  with  its  point,  a  force  exerted  labio-occlusally 
will  dislodge  it  sufficiently  for  the  forceps  to  l)e  applied.  When 
the  root  is  reasonably  strong  and  the  alveolus  firm,  it  is  good 
practice,  before  a])])h  ing  the  elevator,  to  remove  a  part  of  the 
alveolar  process  from  the  root  at  the  point  of  application,  so  as 
to  insure  a  secure  adjustment. 


140  EXTRACTION  TECHNIG  OF  SUPERIOR  TEETH 

Fracture. — Where  a  fracture  of  this  tooth  occurs  while  opera- 
ting on  it,  and  sufficient  structure  remains  for  Standard  forceps 
No.  1  to  be  adjusted,  the  forceps  should  be  quickly  applied,  care 
being  taken  that  in  the  reapplication  the  beaks  do  not  engage 
the  alveolar  process  instead  of  the  tooth.  If  the  fracture  is 
above  the  margin  of  the  process,  recourse  may  be  had  to  the 
screw-porte  or  to  the  Cryer  elevator,  the  latter  being  applied  as 
described  under  cuspid  root  (page  139). 

SUPERIOR  FIRST  AND  SECOND  BICUSPIDS. 

As  the  operations  for  the  removal  of  the  superior  first  and 
second  bicuspids  are  nearly  the  same,  the  extraction  technics 
of  these  two  teeth  are  given  together,  and  attention  is  directed 
to  any  variation  in  the  technic  wherever  it  is  indicated.  Fig.  67 
shows  the  types  of  superior  first  and  second  bicuspids  that  are 
usually  seen. 

Position  of  Patient  and  Operator. — The  position  of  the  patient 
in  the  chair  and  that  of  the  operator  is  as  described  for  extract- 
ing superior  teeth  (page  93).  When  operating  on  the  left  side 
of  the  arch,  the  head  of  the  patient  is  turned  toward  the  opera- 
tor. The  left  arm  of  the  operator  is  placed  around  the  head 
of  the  patient,  with  the  palm  of  the  hand  over  the  left  cheek. 
The  index  finger  raises  the  upper  lip,  exposing  the  field  of 
operation;  the  second  finger  is  placed  on  the  labial  surface  of  the 
inferior  teeth;  the  third  and  fourth  fingers  are  placed  against 
the  lower  part  of  the  cheek  (Fig.  68). 

When  operating  on  the  right  side  of  the  arch,  the  head  of  the 
patient  is  turned  slightly  toward  the  left.  The  third  finger 
raises  the  upper  lip,  exposing  the  field  of  operation;  the  second 
finger  passes  into  the  mouth  and  retracts  the  cheek;  the  index 
finger  is  placed  on  the  buccal  surface  of  the  inferior  teeth,  and 
prevents  the  forceps  from  impinging  on  the  lip  (Fig.  69).  If, 
however,  considerable  resistance  is  encountered,  the  left  arm  of 
the  operator  may  be  placed  around  the  head  of  the  patient  as 
shown  in  Fig.  68,  with  the  arrangement  of  the  hand  and  fingers 
as  described  for  the  cuspid  (page  129),  except  that  the  position 
of  the  fingers  is  a  little  more  posteriorly. 

Forceps.^Standard  forceps  No.  2  (Fig.  2)  are  the  most  suit- 
able for  the  extraction  of  these  teeth,  and  are  adaptable  to  both 
sides  of  the  arch.     These  forceps  are  also  used  in  the  extraction 


SUPERIOR  FIRST  AND  SECOND  BICUSPIDS 


141 


Fig.  67.— Types  of  superior  first  and  second  bicuspids.  First  row — first  four  teeth, 
buccal  surface  of  first  bicuspids;  second  four  teeth,  buccal  surface  of  second  bicus- 
pids. Second  row — first  four  teeth,  lingual  surface  of  first  bicuspids;  second  four 
teeth,  lingual  surface  of  second  bicuspids.  Third  row— first  four  teeth,  mesial  sur- 
face of  first  bicuspids;  second  four  teeth,  mesial  surface  of  second  bicuspids. 
Fourth  row— first  four  teeth,  distal  surface  of  first  bicuspids;  second  four  teeth, 
distal  surface  of  second  bicuspids. 


142 


EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 


of  the  roots  of  the  second  bicuspid  and  the  roots  of  the  first 
bicuspid  when  they  are  firmly  united,  or  when  the  roots  are  en- 
tirely separated  if  they  are  reasonably  stroni*'.  These  forceps, 
the  beaks  of  which  are  known  as  the  bayonet  type,  are  made  in 


Fig.  68. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  a  superior  bicuspid  on  the  left  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.  2)  to  the  superior  left  first  bicuspid. 

several  sizes  by  different  manufacturers,  and  the  operator  may 
select  an  extra  pair  to  suit  his  individual  idea,  which  may  be  a 
very  good  adjunct  to  his  regular  pair. 

Standard  forceps  No.  5  (Fig.  6)  are  suitable  for  extracting  the 
roots  of  the  first  bicuspid  when  they  are  entirely  separated  and 


8UPERIUR  FIR^T  AND  SECOND  BICUSPIDS 


143 


of  small  size,  and  for  removing  the  roots  of  this  tooth  and  the 
second  bicuspid  when  they  are  deeply  seated  in  the  tissues.  They 
are  sometimes  employed  in  removing  either  one  of  these  teeth 
when  wedged  between  the  adjacent  teeth. 


Fig  69.— Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  a  superior  bicuspid  on  the  right  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.   2)   to  the  superior  right  first  bicuspid. 

Standard  special  A  and  special  B  forceps  (Figs.  11,  12)  serve 
their  greatest  use  in  connection  with  these  teeth,  and  were  origi- 
nally designed  for  them.  They  are  used  for  removing  these 
teetii  when  in  partial  or  complete  buccal  or  lingual  occlusion, 
and  when  a  root  is  wedged  between  the  adjacent  teeth. 


144  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

When  accessible,  Standard  forceps  No.  1  (Fig.  1)  may  be  used 
in  the  extraction  of  these  teeth,  if  their  attachment  is  not  very 
firm,  when  this  instrument  has  been  used  in  removing  other 
teeth  at  the  same  operation. 

Order  of  Extraction. — The  extraction  of  the  first  bicuspid  pre- 
cedes that  of  the  cuspid  wherever  such  order  may  indicate  the 
simpler  operation.  Where  the  second  bicuspid  is  also  to  be 
extracted  at  the  same  sitting,  it  should  be  removed  before  the 
first  bicuspid  and  before  the  first  molar  if  both  second  bicuspid 
and  first  molar  are  to  be  removed. 

Application  of  Forceps. — The  application  of  Standard  forceps 
No.  1,  used  in  the  extraction  of  the  six  superior  anterior  teeth,  is 
comparatively  simple,  owing  to  their  beaks  and  handles  being 
in  the  same  line,  but  the  application  of  the  bayonet-shaped  for- 
ceps, used  in  the  extraction  of  the  superior  bicuspids,  with  their 
beaks  set  about  three-quarters  of  an  inch  out  of  line  with  the 
axis  of  the  handles,  requires  greater  caution,  and  care  should 
be  taken  that  the  beaks  of  the  bayonet  forceps  are  also  applied 
in  line  with  the  axis  of  the  tooth.  The  application  of  Standard 
forceps  No.  2  (Fig.  2)  to  a  bicuspid  tooth  is  made  by  passing  one 
beak  well  up  on  the  lingual  side  of  the  tooth,  followed  by  placing 
the  opposite  beak  to  the  buccal  side,  being  practically  the  same 
method  of  application  as  is  made  to  anterior  teeth.  Usually,  in 
making  the  application  to  a  bicuspid,  it  should  be  made  with 
sufficient  force  toward  the  process  to  assist  in  loosening  the 
tooth.  The  mesial  and  distal  application  is  practicable  only 
when  the  tooth  on  either  side  of  the  one  to  be  extracted  has  been 
removed  at  the  same  sitting  and  a  fracture  of  the  bicuspid  has 
occurred. 

Alveolar  Application  of  Forceps. — Alveolar  application  to 
these  teeth  is  very  easil}^  made,  and  is  quite  often  indicated. 
When  the  forceps  are  applied,  adjustment  should  be  made  more 
freely  to  the  buccal  than  to  the  lingual  side  of  the  tooth.  The 
technic  of  application  is  the  same  as  in  the  case  of  central  incisor 
(page  111). 

Extraction  Movements. — With  Standard  forceps  No.  2  securely 
applied  to  the  superior  first  bicuspid  (Fig.  70,  A),  the  first  ex- 
traction movement  is  executed  very  cautiously  to  the  buccal  side 
(Fig.  70,  B).  With  the  exception  of  the  inferior  third  molar, 
this  tooth  is  probably  more  difficult  to  remove,  without  fracture, 


SUPERIOR  FIRST  AND  SECOND  BICUSPIDS 


145 


B 


D 


Fig.  70. — Extraction  movements  for  superior  first  and  second  bicuspids.  A,  forceps 
(Standard  No.  2)  applied;  B.  first  movement  to  the  buccal  side;  C,  reverse  move- 
ment to  the  ling-ual  side;  D,  tractile  movement  downward  in  line  with  the  original 
position  of  the  tooth. 


146  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

than  any  other  tooth  in  the  month.  Even  the  skillful  operator 
will  find  it  impossible  to  remove  this  tooth  intact  in  every  case. 
As  the  root  is  often  bifurcated — at  times  only  partially,  and 
varying  from  partial  to  complete  bifurcation — and  as  it  is  impos- 
sible to  accurately  diagnose  these  conditions  beforehand,  each 
operation  should  proceed  as  though  the  roots  were  extensively 
separated.  In  addition  to  the  uncertainties  in  the  bifurcation, 
the  ends  of  the  roots  above  the  bifurcation  may  incline  anywhere 
from  a  slight  mesial  inclination  to  an  extensive  distal  one,  and 
may  vary  in  curvature  anywhere  from  being  widely  divergent 
to  being  curved  together  at  their  apices.  Frequently  the  tooth 
is  very  much  constricted  at  its  neck,  the  mesio-distal  diameter 
here  often  being  less  than  one-half  of  the  thickness  of  the  crown. 
The  first  extraction  movement  having  been  carefully  applied, 
the  amount  of  resistance  that  has  been  encountered  is  noted,  and 
the  amount  of  force  that  can  be  safely  used  in  the  next  move- 
ment, which  is  to  the  lingual  side  (Fig.  70,  C),  is  judged,  and 
should  be  a  little  more  forcible  than  the  one  to  the  buccal  side. 
If  the  tooth  has  not  been  loosened  by  these  movements,  they 
are  repeated  until  the  attachment  is  broken  up,  when  the  tooth 
is  removed  from  its  socket  by  a  tractile  movement  downward  in 
line  with  its  original  position  (Fig.  70,  D).  This  last  movement 
varies  slightly,  however,  and  the  amount  of  deflection  from  the 
original  j)osition  is  governed  by  the  curvature  of  the  roots.  If 
the  roots  are  widely  divergent,  or  the  curvature  of  the  tips  are 
reversed,  a  slight  swerving  motion  bucco-lingually  during  the 
tractile  movement  will  often  enable  the  operator  to  remove  the 
tooth  from  its  socket  without  fracturing  the  tips.  Occasionally 
it  is  good  practice,  before  completing  the  operation,  to  readjust 
the  forceps  higher  on  the  tooth  as  space  is  gained  in  executing 
the  extraction  movements. 

The  same  extraction  teclmic  applies  to  the  second  bicuspid  as 
to  the  first,  but  it  is  not  necessary  to  proceed  with  the  same  pre- 
caution, as  the  root  of  this  tooth  is  seldom  bifurcated,  and  the 
constriction  at  the  neck  is  less. 

Displacement — Liugual. — Where  a  superior  bicuspid  is  dis- 
placed partially  or  completely  to  the  buccal  or  lingual  side  of 
the  arch,  extraction  is  usually  complicated,  especially  with  the 
first  bicuspid,  owing  to  its  proneness  to  fracture.  When  this 
tooth  is  displaced  to  the  lingual  side  of  the  arch,  the  amount  of 


SUPERIOR  FIRST  AND  SECOND  BICUSPIDS  147 

space  between  it  and  the  adjoining  teeth  is  carefully  observed 
to  ascertain  which  forceps  will  be  most  suitable  for  its  removal. 
If  space  permits,  Standard  forceps  No.  2  are  used,  but  the  cases 
in  which  they  can  be  used  are  comparatively  few,  as  the  appli- 
cation of  the  beaks  of  the  forceps  to  the  buccal  surface  of  the 
tooth  is  one  of  the  difficulties  to  be  overcome  in  its  extraction. 
Standard  special  A  and  special  B  forceps  (Figs.  11,  12)  were 
designed  especially  to  meet  this  condition.  In  their  application 
the  small  beak  is  first  adjusted  as  far  up  on  the  buccal  surface 
as  space  will  permit,  and  the  opposite  beak  is  brought  over  to 
engage  the  lingual  surface.  When  applied  in  this  way,  a  cau- 
tious movement  is  made  liugually,  exercising  care  that  the  small 
beak  does  not  slip  from  its  adjustment,  and  noting  the  amount 
of  resistance  offered  by  the  tooth.  If  some  space  has  been 
gained  by  this  movement,  a  readjustment  is  made  so  as  to  bring 
the  small  beak  as  far  as  possible  up  on  the  tooth,  when  a  similar 
lingual  movement  is  again  executed.  The  space  thus  gained  is 
taken  up  each  time  by  a  buccal  movement,  and  these  movements 
are  repeated  until  its  attachment  has  been  broken  up,  when  it  is 
removed  by  a  tractile  movement  as  nearly  as  possible  in  the 
direction  of  its  axis.  Greater  force  is  permissible  with  this  trac- 
tile movement  than  is  allowed  in  extracting  the  same  tooth  in 
normal  occlusion.  The  technic  for  extracting  the  first  bicuspid 
is  also  applicable  to  the  removal  of  the  second  bicuspid  when  in 
similar  displacement. 

Where  the  superior  second  bicuspid  is  completely  displaced 
liugually  and  in  close  proximity  to  the  first  molar  (Fig.  71),  the 
application  of  the  modified  Cryer  elevator  (Fig.  25)  to  its  distal 
surface  (Fig.  72),  preceding  the  adjustment  of  the  forceps,  is 
usually  good  procedure.  In  the  application  of  the  elevator  the 
mesio-lingual  angle  of  the  molar  and  the  process  about  it  are 
used  as  a  fulcrum,  followed  by  the  usual  pressure  upward  to 
engage  the  tooth  with  the  point  of  the  instrument,  when  it  is 
forced  downward  and  away  from  the  adjoining  teeth.  The  same 
procedure  is  applicable  to  the  superior  first  bicuspid  when  situ- 
ated in  similar  relation  to  the  second  bicuspid,  but  care  must  be 
exercised  in  the  application  of  the  elevator,  lest  also  the  second 
bicuspid  be  loosened. 

As  the  amount  of  displacement  varies  greatly  with  these  teeth, 
and  as  they  are  nearly  always  more  or  less  rotated,  the  operator 


148  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

slioulcl  possess  sufficient  ingenuity  to  be  able  to  select  the  teclmic 
of  operation  Ijest  suited  for  each  case  presented,  bearing  in  mind 
that  the  bicuspid  teeth  are  much  flattened  in  their  mesio-distal 
diameter,  and  that,  when  displaced  to  the  lingual  side  of  the 
arch,  they  are  more  or  less  wedged  between  the  adjoining  teeth 
on  the  one  side  and  the  firm  palatal  wall  of  the  alveolar  process 
on  the  opposite.  The  operator  should  never  be  hasty  in  the 
application  of  the  movements,  but,  while  grasping  the  tooth 
firmly,  execute  a  short,  steady  movement  in  the  direction  of  least 
resistance,  and  never  lose  sight  of  the  tooth's  greatest  diameter, 
as  a  very  small  amount  of  force  in  the  opposite  direction  will 
usuallv  result  in  fracture. 


Fig-.   71. — Superior    second     bicuspid     dis-        Fig.    72. — Cryer  elevator  applied  to  a   su- 
placed  to  the  lingual  side  of  the  arch.  perior  second  bicuspid  displaced  to  the 

lingual  side  of  the  arch. 

Buccal. — AVhere  one  of  these  teeth  is  displaced  buccall}^,  as 
where  displaced  lingually,  Standard  forceps  No.  2  are  used  for 
its  removal  wherever  adjustment  can  be  had  with  them.  Where 
the  displacement  is  only  partial,  and  the  intervening  space  be- 
tween the  approximating  teeth  is  not  entirely  closed,  either 
Standard  special  A  or  special  B  forceps  are  adaptable  to  the  con- 
dition. AVhen  one  of  these  forceps  are  used,  the  application  is  the 
same  as  in  the  case  of  lingual  displacement  (page  146),  always 
applying  the  smaller  beak  first  and  being  careful  not  to  let  it  slip 
from  its  adjustment.  The  forceps  having  been  applied,  the  same 
movements,  but  in  a  reverse  direction,  are  used  as  have  been  de- 
scribed for  lingual  displacement  (page  146).     After  adjustment 


SUPERIOR  FIRST  AND  SECOND  BICUSPIDS  149 

lias  been  made,  extraction  is  nsnally  not  difficult,  owing  to  the 
weakened  condition  of  the  external  plate  of  the  process.  There 
is  often  greater  danger  of  tearing  away  the  process  than  of  frac- 
turing the  tooth.  Where  space  will  not  allow  the  application  of 
forceps,  the  tooth  can  often  he  tipped  away  from  an  adjoining 
tooth  with  the  Cryer  elevator  to  permit  their  application.  When 
using  the  elevator,  care  must  be  taken  that  it  does  not  slip  from 
its  adjustment  and  do  serious  injury  to  the  surrounding  tissues. 

Extensive  Caries. — Where  one  of  tliese  teeth  is  attacked  by 
caries  on  the  l)U('cal  surface,  especially  when  it  extends  above 
the  gum  margin,  the  condition  favors  a  greater  buccal  movement 
in  its  extraction.  With  the  forceps  applied  in  the  usual  way, 
and  the  adjustment  as  far  up  as  possible  on  the  tooth,  the  prin- 
cipal movement  of  extraction  is  to  the  buccal  side,  with  just 
enough  lingual  movement  to  take  up  the  space  that  has  been 
gained  by  the  buccal  movement.  If  the  decay  is  extensive  above 
the  gingival  line  lingually,  very  little  movement  is  permissible 
buccally,  and  a  careful  lingual  and  a  greater  tractile  movement 
should  be  executed  to  remove  the  tooth. 

Where  there  is  extensive  mesial  or  distal  decay — and  as  it  is 
always  desirable  to  remove  the  tooth  in  fofo  when  possible,  and 
especially  is  this  desirable  in  the  case  of  the  first  bicuspid  if 
decay  has  not  extended  above  the  bifurcation  of  the  roots — 
alveolar  application  is  permissible  and  advised  in  these  cases. 

Bicuspid  Roots. — AVhere  the  crown  of  a  bicuspid  is  destroyed, 
leaving  only  the  root,  application  is  made  with  Standard  for- 
ceps No.  2  as  far  up  on  the  root  as  the  process  will  permit,  and 
the  root  is  removed  in  the  same  manner  as  though  the  crown  were 
intact,  using,  however,  greater  precaution  in  the  execution  of  the 
extraction  movements.  If  the  part  of  the  root  below  the  process 
does  not  possess  sufficient  strength  to  withstand  the  extraction 
movements,  alveolar  application  should  be  made.  Some  marginal 
alveolar  caries  is  nearly  always  present  with  these  teeth  when 
decay  is  extensive,  and  an  alveolar  application  in  such  case  is 
comparatively  easy.  Where  caries  of  the  process  is  not  present, 
it  is  usually  better,  when  this  method  of  application  is  followed, 
to  cut  through  a  part  of  the  process,  to  secure  an  adjustment, 
than  to  take  the  risk  of  spreading  the  process  by  a  too  forcible 
upward  pressure  of  the  forceps,  and  cutting  the  process  usually 
insures  an  intact  removal. 


150  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

The  extraction  of  the  first  bicuspid  where  decay  has  not  pro- 
gressed far  enough  to  separate  its  roots  (Fig.  73)  is  performed 
with  Standard  forceps  No.  2  as  though  only  one  root  existed.  In 
the  application  of  the  forceps,  the  beak  is  first  applied  to  the 
side  of  the  root  where  decay  is  most  extensive,  as  this  method 
affords  a  better  adjustment.  Where  the  two  roots  are  separated 
(Fig.  74),  Standard  forceps  No.  2  are  used,  and  the  two  roots  are 
taken  out  separately.  If  the  two  roots  are  extensively  decayed, 
or  situated  in  close  proximity  to  each  other.  Standard  forceps 
No.  5  are  most  suitable  for  their  removal.  Application  is  always 
made  first  to  the  stronger  and  more  accessible  root.     Where  the 


Fig.    73. — Superior      first     bicuspid      witli  Fig.  74. — Same  subject  as  Fig.   73.     Decay 

crown  destroyed  by  caries.    Decay  has  lias  extended  so  far  that  the  roots  are 

not  extended   far  enough   to   separate  separated, 
the  roots. 

roots  are  to  be  extracted  separately,  a  slight  rotatory  movement 
is  often  permissible.  In  rare  cases  this  tooth  possesses  a 
third  root,  which  is  formed  by  a  bifurcation  of  its  buccal  root. 
Although  this  latter  condition  is  not  of  frequent  occurrence,  it  is 
well  to  know  of  the  possibility  of  its  existence,  for,  if  present,  the 
third  root  may  be  left  unextracted  and  the  operator  fully  believe 
that  all  of  the  tooth  has  been  removed. 

Where  deca}'^  is  extensive  with  the  buccal  root  of  the  first 
bicuspid,  the  process  is  often  carious  in  this  region.  When  this 
condition  exists,  the  operator  should  use  more  than  ordinary  care 
in  his  efforts  to  grasp  the  buccal  root,  or,  in  attempting  to  apply 
the  forceps  to  the  lingual  root,  see  that  the  beak  does  not  strike 


SUPERIOR  B'lRST  AND  SECOND  BICUSPIDS  151 

against  the  buccal  root,  for  in  either  case  there  is  liability  of 
forcing  the  buccal  root  high  into  the  soft  tissues  (Fig.  75).  Such 
displacement  of  the  buccal  root  will,  however,  sometimes  occur, 
and,  when  it  does  take  place,  the  operator  should  discontinue  the 
use  of  the  forceps  and  flush  the  socket  until  hemorrhage  has 
stopped,  when  the  misplaced  root  is  to  be  relocated,  which  is 
done  by  passing  the  finger  over  the  soft  tissue  on  the  buccal  side. 
When  the  root  has  been  located,  it  is  again  forced  down  into  its 
socket  by  pressure  on  the  parts  above  it,  after  which  it  may,  with 
care,  be  removed  with  the  Derenberg  tweezers,  or  an  explorer  is 
passed  up  so  as  to  engage  the  root  and  withdraw  it  from  its 
lodgment. 

Bicuspid  roots  are  frequently  covered  by  gum  tissue,  and, 
when  so  covered,  the  procedure  is  as  described  and  illustrated 
for  central  incisor  (page  116).     In  applying  this  procedure  to  a 


Fig.  75. — Buccal    root    of    a    superior   bicuspid    displaced   into    the    soft   tissue   external 
of  the  socket.     Position   of  the  root  is  indicated  by  dotted  lines. 

second  bicuspid  root,  the  operator  should  bear  in  mind  that  its 
apex  often  terminates  in  close  proximity  to  the  maxillary  sinus, 
and  he  should  be  sure  that  the  forceps  are  opened  sufficiently  to 
engage  the  root,  and  not  press  upward  on  it,  as  by  such  pressure 
the  root  may  be  forced  into  this  sinus.  In  using  the  forceps  to 
dilate  the  soft  tissues  over  a  broken-down  superior  first  bicuspid, 
great  care  is  required  in  making  the  application  on  account  of 
the  probable  presence  of  two  roots. 

Screw-Porte. — The  screw-porte  is  not  a  practical  instrument 
for  the  removal  of  the  roots  of  a  superior  first  bicuspid,  as  the 
bifurcation  of  the  root  will  not  permit  the  use  of  the  screw-porte. 
Sometimes  the  screw-porte  can  be  used  in  removing  the  root  of 
a  superior  second  bicuspid  if  access  can  be  secured  and  the  root 
has  only  one  canal.  As  a  rule,  the  instrument  is  not  practical 
for  removing  the  latter  root,  and  its  use  is  not  attempted  unless 


152  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

the  root  cannot  be  removed  in  any  other  way  without  consider- 
able destruction  of  tissue. 

Elevator.^ — The  elevator  is  not  as  practical  for  the  extraction 
of  the  roots  of  the  superior  first  bicuspid  as  for  the  roots  of  the 
teeth  anterior  to  it,  and  is  seldom  used  for  this  purpose,  except 
in  case  of  malocclusion  or  where  a  fracture  has  occurred.  The 
use  of  the  elevator  where  either  of  the  latter  conditions  exists 
is  described  under  displacement  and  fracture  (page  146  and 
below  under  fracture).  Cases  will  occur  where  the  roots  are 
small  and  not  firmly  attached,  when  the  straight-shank  elevator 
(Fig.  15)  may  be  applied,  and  is  used  by  adjusting  it  to  the 
buccal  surface  of  the  roots  and  dislodging  them  with  a  pushing 
movement  to  the  lingual  side. 

A  number  of  elevators  are  made  with  the  blade  shaped  in  the 
form  of  a  hook,  any  one  of  which  is  used  by  applying  the  elevator 
to  the  lingual  side  and  removing  the  tooth  with  a  pulling  motion 
to  the  buccal  side.  The  use  of  such  elevator  is  left  to  the  choice 
of  the  operator,  as,  wherever  it  can  be  applied,  delivery  can  also 
be  accomplished  with  the  forceps. 

The  elevator  is  used  more  frequently  on  the  second  bicuspid 
than  on  the  first.  The  Cryer  elevator  (Fig.  24)  is  the  one  best 
adapted  for  use  on  the  second  bicuspid,  and  is  especially  ajipli- 
cable  for  the  removal  of  a  root  covered  by  gum  tissue  and  where 
deeply  seated,  as  with  its  use  in  these  cases  the  tissues  are  con- 
served. Wherever  possible,  application  should  be  made  to  the 
distal  side  of  the  root,  and,  if  application  cannot  be  had  distally, 
a  mesial  application  may  be  made.  The  modified  Cryer  ele- 
vator (Fig.  25)  should  be  used  when  operating  on  the  left  side  of 
the  mouth.  When  making  the  application  of  the  elevator  to  this 
tooth,  care  should  be  taken  that  the  point  of  the  instrument  is 
introduced  between  the  process  and  the  root,  and  not  against  the 
end  of  the  root. 

Impacted  Teeth. — The  superior  bicuspids  are  seldom  found 
impacted,  and,  when  that  condition  exists,  they  are  usually  dis- 
placed either  to  the  lingual  or  buccal  side  of  the  arch.  The 
technic  of  operation  is  the  same  as  for  the  cuspid  when  impacted 
(page  137). 

Fracture. — A  fracture  of  the  superior  first  bicuspid  is  of  fre- 
quent occurrence,  and  is  sometimes  unavoidable.  When  fracture 
does  occur,  the  error  should  not  be  made  of  attempting  to  hastily 


SUPERIOR  FIRST  AND  SECOND  MOLARS  153 

complete  the  operation  by  repeated  application  of  the  forceps, 
which  nsnally  results  only  in  repeated  fracture  of  the  tooth.  A 
careful  examination  should  be  made  and  the  existing  condition 
ascertained,  in  order  that  the  operation  may  not  be  continued 
in  an  ineffective  manner.  If  an  examination  reveals  that  the 
process  surrounding  the  tooth  is  carious,  or  that  the  alveolar 
margin  is  not  heavy,  alveolar  application  may  be  made  and  the 
tooth  removed  by  the  usual  alveolar  method.  If  fracture  occurs 
a  short  distance  above  the  margins  of  the  process,  and  the  process 
is  heavy,  the  latter  should  be  removed  with  a  bur  and  a  new 
application  of  the  forceps  made.  If  the  cuspid  and  second 
bicuspid  have  been  removed  at  the  same  sitting,  a  mesio-distal 
application  can  often  be  advantageously  made. 

If  the  fracture  is  quite  a  distance  above  the  process,  and  the 
two  roots  are  held  firmly  together,  the  roots  are  separated  at 
their  bifurcation  with  a  bur  and  an  elevator  is  adjusted  between 
them,  using  one  of  the  roots  as  a  fulcrum  to  dislodge  the  opposing 
one.  If  only  one  root  remains,  Standard  forceps  No.  5  (Fig.  6) 
are  adjusted,  and  the  root  slightly  rotated,  when  it  is  carried 
from  its  socket  by  a  tractile  movement.  If  only  a  small  tip  of 
the  root  remains,  and  no  pathologic  condition  exists,  it  may  be 
left  undisturbed.  If,  however,  a  pathologic  condition  is  present 
in  connection  with  the  tip,  it  will  be  necessary  to  remove  the  tip 
with  a  bur,  but  the  bur  should  be  used  only  Avhere  the  part 
remaining  is  inaccessible  to  forceps  or  elevator.  In  case  tips 
of  each  of  two  roots  remain,  the  procedure  will  be  the  same  as 
where  one  tip  remains. 

Fracture  is  not  so  frequent  with  the  superior  second  bicuspid, 
but,  if  it  occurs,  the  technic  of  operation  is  the  same  as  for  the 
first  bicuspid,  as  described  above  where  a  fracture  of  the  latter 
tooth  occurs  not  far  enough  above  the  process  to  separate  its 
roots  or  to  demand  the  separation  of  the  roots  for  their  removal. 

SUPERIOR  FIRST  AND  SECOND  MOLARS. 

As  with  the  superior  bicuspids,  the  extraction  technics  of  the 
superior  first  and  second  molars  are  so  nearly  the  same  that  the 
operations  for  these  teeth  are  given  together,  and,  as  with  the 
bicuspids,  attention  is  directed  to  any  variation  of  operation  that 
may  be  applied  to  either  tooth.  Fig.  76  shows  the  types  of  supe- 
rior first  and  second  molars  that  are  usually  seen. 


154  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

Position  of  Patient  and  Operator. — The  position  of  the  patient 
in  the  chair  and  that  of  the  operator  is  as  described  for  extract- 
ing superior  teeth  (page  93).  When  removing  these  teeth,  tlie 
chair  may  be  raised  a  little  higher  than  for  the  teeth  anterior  to 
them,  but  should  not  be  raised  too  high,  as  better  control  of  the 
muscles  is  had  when  the  body  is  slightly  crouched. 

When  operating  on  the  left  side  of  the  arch,  the  head  of  the 
patient  is  turned  toward  the  operator.  The  position  of  the  arm 
of  the  operator  and  the  arrangement  of  the  hand  and  fingers  are 
as  described  for  the  first  and  second  bicuspids  (page  140),  except 
that  the  position  of  the  fingers  is  a  little  posterior  to  that  used 
for  the  bicuspids  (Fig.  77). 

When  operating  on  the  right  side  of  the  arch,  the  head  of  the 
patient  is  turned  toward  the  left.  The  arrangement  of  the  hand 
and  fingers  are  as  described  for  the  first  and  second  bicuspids 
(page  140),  except  that  the  position  of  the  fingers  is  a  little  more 
posterior  (Fig.  78).  If,  however,  any  difficulty  is  encountered, 
the  left  arm  of  the  operator  may  be  placed  around  the  head  of  the 
patient  as  shown  in  Fig.  64,  with  the  arrangement  of  the  hand 
and  fingers  as  described  for  the  cuspid  (page  129),  except  that 
the  lips  are  drawn  further  back  to  expose  the  field  of  operation. 

Forceps. — It  is  necessary  that  the  operator  possess  separate 
forceps  for  each  side  of  the  arch,  the  construction  of  the  two  for- 
ceps being  the  same,  except  that  the  beaks  of  one  have  reversed 
position  from  that  of  the  other,  and  these  two  forceps  are  usually 
referred  to  as  rights  and  lefts.  The  selection  of  suitable  forceps 
for  extracting  these  teeth  is  an  important  matter,  as  the  instru- 
ment to  be  used  must  bear  the  great  strain  imposed  on  it,  and  the 
beaks  must  be  so  shaped  that  they  are  adaptable  to  the  necks  of 
the  tooth  while  grasping  the  greatest  amount  of  its  surface. 
Standard  forceps  No.  3  E  and  No.  3  L  (Figs.  3,  4)  meet  these 
requirements,  and  are  used  wherever  the  crown  is  intact,  or 
where  the  greater  part  of  it  remains,  and  the  tooth  is  firmly 
attached  to  the  tissues.  These  forceps  are  so  constructed  that 
they  can  be  advantageously  used  in  almost  all  cases  where  extrac- 
tion is  indicated.  In  addition  to  these  twc  instruments.  Stand- 
ard forceps  No.  4  (Fig.  5),  which  are  designed  for  the  superior 
third  molar,  are  occasionally  employed  for  a  first  or  second  molar 
when  the  tooth  is  loose  or  the  crown  is  malformed.  Standard 
forceps  No.  2  (Fig.  2)  are  also  used  in  the  extraction  of  the  tooth 


SUPERIOR  FIRST  AND  SECOND  MOLARS 


155 


Fig.  76.— Types  of  superior  first  and  second  molars.  The  first  row  shows  the  buccal, 
the  second  row  the  lingual,  the  third  row  the  mesial,  and  the  fourth  row  the  distal 
surface. 


156 


EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 


where  the  crown  has  been  destroyed  by  caries  and  only  the  roots 
remain. 

Where  the  operator  is  using  either  Standard  forceps  No.  3  K 
or  No.  3  L  and  suspects  a  probable  fracture  of  the  crown  or 


Fig.  77. — Position  of  the  operator's  hands  and  disposition  of  tlie  fingers  wiien  applying 
forceps  to  a  superior  molar  on  the  left  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.  3  L)  to  the  superior  left  first  molar. 

breaking  up  of  its  roots,  he  should  have  Standard  forceps  No.  2 
either  in  the  hand  of  his  assistant  or  within  eas}^  reach,  so  that 
they  can  be  quickly  applied  if  a  fracture  occurs  or  if  one  of  the 
roots  remains  unextracted.  Especially  should  this  precaution  be 
taken  when  a  patient  is  under  a  general  anesthetic. 


SUPERIOR  FIRST  AND  SECOND  MOLARS  157 

Order  of  Extraction. — The  extraction  of  the  superior  second 
bicuspid  precedes  tliat  of  the  first  molar  when  necessary  to  re- 
move both  of  these  teeth.  If  the  second  molar  is  to  be  extracted 
at  the  same  sitting,  it  is  taken  out  before  the  first  molar,  espe- 


Fig.  78. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  a  superior  molar  on  the  right  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.  3  R)  to  the  superior  right  first  molar. 

cially  if  some  difficulty  is  anticipated  in  the  extraction  of  the  first 
molar.  Where  also  the  third  molar  is  to  be  removed  at  the  same 
sitting,  the  second  molar  is  removed  before  the  third  molar  only 
when  it  is  difficult  to  gain  access  to  the  third  molar  and  when  the 
removal  of  the  second  will  facilitate  the  removal  of  the  third. 


158  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

Application  of  Forceps. — The  proper  application  of  the  beaks 
of  the  forceps  to  these  teetli  is  important,  as  a  firm  adjustment 
greatly  aids  the  operator  in  the  extraction  movements  that 
follow.  In  making  the  application,  the  axis  of  the  tooth,  as  in 
the  case  of  the  bicuspids,  should  be  carefully  observed,  as  here 
there  are  three  roots  with  which  to  contend.  The  forceps  having 
been  selected,  the  oval  blade  is  adjusted  to  the  lingual  surface  of 
the  tooth,  followed  by  the  application  of  the  opposite  beak  of  the 
buccal  surface.  In  making  this  application,  the  lingual  adjust- 
ment must  extend  well  up  to  the  alveolar  process,  and  care  must 
be  taken  that  the  point  of  the  buccal  beak  passes  between  the 
buccal  roots,  so  that  the  forceps  will  not  slip  from  their  adjust- 
ment when  force  is  applied,  as  considerable  pressure  gingivally 
is  required  in  making  this  application.  Occasionally,  when  ac- 
cess is  difficult,  due  to  heavy  cheeks  or  other  conditions,  the  order 
of  application  of  the  beaks  to  the  second  molar  is  reversed,  and 
the  first  application  is  made  to  the  buccal  surface  of  the  tooth. 

It  is  not  uncommon  with  these  teeth,  especially  with  the  second 
molar,  that  the  bifurcation  of  the  roots  is  not  complete,  the  two 
buccal  roots  or  the  disto-buccal  and  the  lingual  roots  being  united 
into  one  broad  root.  In  either  case  the  crown  of  the  tooth  is 
usually  diverted  from  its  imperfect  rhombic  form  to  one  more 
nearly  rhomboidal,  and  sometimes  even  to  that  of  an  imperfect 
trapeziform.  Where  this  condition  is  present,  it  must  be  care- 
fully observed  in  making  the  application  of  the  forceps,  as  the 
force  of  the  extraction  movement  has  a  tendency  to  slide  the 
beaks  around  the  neck,  especially  if  the  small  tip  on  the  buccal 
beak  is  not  properly  engaged.  In  such  case  better  application 
can  be  had  with  Standard  forceps  No.  4  (Fig.  5)  than  with  the 
regular  forceps  designed  for  the  superior  molars. 

The  superior  molars  are  frequently  inclined  mesially,  due  to 
the  loss  of  the  immediate  tooth  in  front.  Where  so  inclined,  the 
amount  of  inclination  must  be  carefully  judged,  as,  when  the 
forceps  are  applied,  their  beaks  and  handles  must  be  applied  in 
lino  with  the  axis  of  the  tooth. 

Alveolar  Application  of  Forceps. — No  attempt  should  be  made 
to  secure  an  alveolar  application  to  these  teeth,  as  the  beaks  of 
the  forceps  cannot  penetrate  the  alveolar  process,  when  normal, 
without  causing  an  unnecessary  amount  of  destruction  to  this 
tissue.    Where  an  alveolar  application  would  ordinarily  be  indi- 


SUPERIOR  FIRST  AND  SECOND  MOLARS  159 

Ccited,  but  the  alveolus  interferes  with  the  adjustment,  removal 
of  the  process  from  the  neck  of  the  tooth  with  a  cross-cut  fissure 
bur  is  the  better  technic.  Alveolar  application  is  especially  con- 
traindicated  with  the  second  molar  when  the  third  is  missing,  as 
a  fracture  of  the  tuberosity  may  result. 

Extraction  Movements. — The  forceps  having  been  adjusted 
(Fig.  79,  A),  with  a  firm  grip  on  the  tooth  and  with  the  hand 
well  down  on  the  handle  of  the  forceps,  the  operator  directs  the 
first  movement  to  the  buccal  side  (Fig.  79,  B).  Too  much  pres- 
sure should  not,  however,  be  exerted  on  this  initial  movement, 
as  the  firm  or  loose  condition  of  these  teeth  is  usually  of  an 
extreme  character — that  is,  they  are  either  easily  removed,  as 
when  the  tissues  supporting  them  are  weakened  by  disease,  or 
they  are  poorly  developed;  or  they  are  firmly  attached,  as  when 
the  tissues  are  normal  and  healthy,  and  development  is  complete. 
The  first  extraction  movement  having  been  made,  the  next  move- 
ment is  to  the  lingual  side  (Fig.  79,  C),  with  about  the  same 
amount  of  force.  These  two  movements  having  been  made,  the 
tooth  is  brought  with  increased  force  buccally  (Fig.  79,  D). 
These  movements  are  usually  sufficient  to  loosen  the  tooth  from 
its  attachment,  but,  if  not,  the  movements  are  repeated  with 
increased  force  until  the  attachment  is  broken  up,  when  the  tooth 
is  carried  back  to  its  original  position  and  removed  from  the 
socket  with  a  tractile  movement  downward  (Fig.  79,  E). 

Where  the  roots  of  these  teeth  are  markedly  divergent,  which 
is  not  uncommon  with  the  first  molar,  much  resistance  is  often 
encountered,  and  the  extraction  movements  must  be  executed 
firmly,  but  not  too  forcibly.  If  too  great  force  is  applied,  one 
or  more  of  the  roots  may  be  fractured,  or  a  large  area  of  the 
buccal  plate  of  the  alveolar  process  may  be  removed,  or  the 
tooth  on  one  side  or  the  teeth  on  both  sides  of  the  one  being- 
extracted  may  be  carried  from  its  socket.  No  tractile  movement 
downward  should  be  attempted  until  the  tooth  has  been  suffi- 
ciently luxated  to  expand  the  alveolus  enough  to  allow  its  exit 
from  the  socket.  The  operator  should  not  be  too  hasty  in  the 
extraction,  but  should  proceed  cautiously  and  with  precision, 
carefully  observing  the  result  of  every  movement  in  order  that 
the  force  to  be  used  in  the  movement  to  follow  may  be  carefully 
judged.  In  addition  to  the  contingencies  mentioned  in  connec- 
tion with  these  teeth,  they  are  also  subject  to  fracture  at  their 


160 


EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 


D 


Fig.  79.^ — Extraction  movements  for  superior  first  and  second  molars.  A,  forceps 
(Standard  No.  3  L)  applied;  B.  first  movement  to  the  buccal  side;  C,  reversed 
movement  to  the  lingual  side;  D.  movement  B  more  forcibly  repeated;  E,  tractile 
movement  downward  in  line  with   the  original  position  of  the  tooth. 


SUPERIOR  FIRST  AND  SECOND  MOLARS  161 

necks,  and  too  great  a  force  in  the  application  of  the  tractile 
movement  or  excessive  pressure  on  the  beaks  of  the  forceps 
while  any  of  the  movements  are  being  executed  should  be 
avoided. 

If  it  is  noted  during  the  extraction  movements  that  the  buccal 
plate  of  the  process  is  being  endangered,  the  movements  should 
be  discontinued  and  a  better  application  of  the  forceps  made. 
If  it  is  impossible  to  preserve  the  external  plate  of  the  process 
in  this  manner,  the  tooth  should  be  removed  in  sections.  If  any 
disturbance  to  an  adjacent  tooth  is  noticed,  the  operator's  thumb 
should  be  placed  on  the  imperiled  tooth  in  order  to  hold  it  in 
position  while  completing  the  operation.  If  the  teeth  on  both 
sides  of  the  one  being  removed  are  disturbed,  it  will  be  better 
to  discontinue  the  extraction  movements  and  remove  the  tooth 
in  sections  than  to  cause  the  loss  of  an  adjacent  tooth. 

Where  these  teeth  are  inclined  mesially,  which  is  not  an 
uncommon  occurrence,  or  are  inclined  in  any  other  direction 
than  normal,  care  should  he  taken  that  all  the  extraction  move- 
ments are  made  with  the  forceps  in  line  with  the  inclination  of 
the  tooth's  axis,  as  all  the  force  executed  at  an  angle  to  the 
tooth's  axis  results  in  just  so  much  force  being  exerted  trans- 
versely on  the  tooth  at  its  neck,  and  does  not  aid  in  breaking  up 
the  attachment  of  the  tooth  from  the  tissues,  but  adds  that  much 
force  to  a  probable  fracture  at  its  neck. 

Displacement. — These  teeth  are  rarely  found  completely  out 
of  alignment,  and  the  author  has  never  had  occasion  to  operate 
on  a  superior  first  molar  so  situated.  On  rare  occasions  such 
tooth  may  be  partially  displaced  buccally  or  lingually,  but  the 
displacement  is  usually  very  slight,  and,  when  such  a  case  is 
presented,  the  use  of  either  Standard  forceps  No.  3  R  or  No.  3  L 
(Figs.  3,  4),  if  their  adjustment  can  be  obtained,  is  preferred. 
If,  however,  these  forceps  cannot  be  applied,  then  Standard 
forceps  No.  2  (Fig.  2)  are  used,  first  applying  one  beak  to  the 
surface  on  which  the  space  is  narrowed  by  the  displacement,  and 
then  applying  the  opposing  beak  to  the  opposite  surface.  Stand- 
ard forceps  No.  2  should  be  used  only  to  gain  an  adjusting  space 
for  Standard  forceps  No.  3  R  or  No.  3  L,  and,  as  soon  as  sufficient 
space  has  been  gained,  the  tooth  is  released  and  application  is 
made  with  the  latter  instrument.  The  first  extraction  movement 
is  made  to  the  lingual  side  in  lingual  displacement,  and  to  the 


162  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

buccal  side  in  buccal  displacement.  The  extraction  movements 
should  follow,  as  closely  as  possible,  the  movements  described 
for  the  removal  of  the  tooth  in  normal  alignment  (page  159). 

Caries  on  Buccal  Surface. — AVhere  decay  is  extensive  on  the 
buccal  surface  of  these  teeth,  the  forceps  are  tirst  adjusted  to 
this  surface  of  the  tooth,  sending  the  blade  as  far  as  possible 
under  the  gum  tissue  with  a  degree  of  pressure  varying  with  the 
amount  of  decay  and  the  size  of  the  tooth,  the  object  being  to  get 
a  good  adaptation  at  the  bifurcation  of  the  buccal  roots. 

The  first  extraction  movement  is  directed  quite  forcibly  to  the 
buccal  side.  The  movement  to  the  lingual  side  is  made  cau- 
tiously and  with  little  force,  the  operator  observing  the  buccal 
blade  carefully  to  see  that  it  does  not  slip  from  its  adjustment. 
A  forcible  movement  is  again  made  to  the  buccal  side,  which  has 
a  tendency  to  send  the  beaks  further  up  on  the  root.  These 
movements  from  the  lingual  to  the  buccal  side  and  vice  versa 
should  be  continued  until  the  tooth  is  loosened  from  its  attach- 
ment, when  it  is  brought  back  to  its  original  position  and  carried 
downward  from  the  socket  with  a  tractile  movement.  If  the 
attachment  is  unusually  strong,  a  reapplication  of  the  forceps 
higher  up  on  the  tooth  will  be  necessary  before  completing  the 
extraction  movements,  but  care  must  be  taken  not  to  engage 
healthy  process  in  the  beaks  when  making  the  reapplication. 

Caries  on  Lingual  Surface. — Where  these  teeth  are  decayed  on 
the  lingual  surface,  one  beak  of  the  forceps  is  first  adjusted  well 
up  on  this  surface  of  the  tooth,  followed  by  applying  the  opposing 
beak  to  the  buccal  surface.  If  the  decay  extends  well  above  the 
gum  margin,  the  inclination  of  the  crown  of  the  tooth  must  be 
noted,  so  that,  in  forcing  the  beaks  of  the  forceps  up  on  this 
surface  of  the  tooth,  it  is  sent  in  the  right  direction.  The  inter- 
proximal alveolus  on  the  mesial  and  distal  sides  of  these  teeth 
is  heavy,  and  the  same  is  true  of  the  alveolar  ridge  along  their 
lingual  sides.  This  condition  must  be  borne  in  mind,  so  that, 
when  application  is  made,  the  process  is  not  engaged  instead  of 
the  tooth. 

The  first  extraction  movement  is  to  the  lingual  side,  but  should 
not  be  too  forcible,  and  should  be  carefully  guarded.  If  the 
movement  is  carefully  executed,  it  will  serve  to  send  the  beak  of 
the  forceps  further  up  on  the  lingual  root  of  the  tooth.  The  next 
movement  is  made  buccally  with  as  much  force  as  the  lingual 


SUPERIOR  FIRST  AND  SECOND  MOLARS  163 

wall  will  bear  without  fracture.  These  movements  should  be 
continued,  swaying  the  tooth  backward  and  forward  linguo 
buccally  until  loosened,  when  it  is  carried  from  its  socket  in  a 
direction  downward  approximating  its  original  position.  The 
amount  of  stress  that  a  tooth  decayed  in  this  manner  will  with- 
stand is  problematic,  and  a  certain  sense  of  touch  must  be  culti- 
vated by  the  operator  so  that  he  may  apply  a  maximum  amount 
of  force  to  break  up  its  attachment  without  exceeding  the 
strength  of  the  crown  and  causing  a  fracture. 

If,  in  executing  the  extraction  movements,  the  lingual  root  is 
separated  from  the  crown,  but  the  forceps  still  hold  the  buccal 
roots  securely,  the  extraction  of  the  latter  should  be  completed, 
after  which  the  lingual  root  can  be  removed  with  Standard 
forceps  No.  2  (Fig.  2).  The  right-and-left  rotatory  movement 
is  nearly  always  permissible  in  extracting  the  lingual  roots  of 
these  teeth. 

Extensive  Caries. — Where  these  teeth  are  attacked  by  exten- 
sive caries  on  their  mesial  or  distal  surface,  and  a  careful  exami- 
nation convinces  the  operator  that  sufficient  structure  remains 
for  the  extraction  of  the  roots  intact,  application  and  extraction 
with  Standard  forceps  No.  3  R  or  No.  3  L  (Figs.  3,  4)  are  per- 
formed in  the  usual  way.  If  decay  is  more  extensive,  but  the 
parts  remaining  possess  sufficient  streng-th,  Standard  forceps 
No.  2  are  sometimes  substituted.  If  decay  is  so  extensive  as  to 
so  weaken  the  tooth  that  it  cannot  be  taken  out  intact,  extraction 
is  performed  in  the  same  manner  as  when  operating  on  roots 
(pages  163-166). 

Fused  Roots. — Two-rooted  superior  molars  are  not  uncommon, 
especially  in  the  case  of  the  second  molar.  These  roots,  when 
present,  are  usually  formed  by  the  union  of  the  disto-buccal  and 
lingual  roots,  but  are  occasionally  formed  by  the  two  buccal 
roots.  Where  this  condition  exists,  if  the  roots  are  short  and 
the  process  not  heavy,  they  are  easily  dislodged  from  their 
sockets,  but,  if  the  process  is  heavy  or  the  fused  root  is  long, 
curved,  or  deeply  grooved,  extraction  may  be  a  very  difficult 
operation.  This  condition  can  usually  be  diagnosed  by  the  shape 
of  the  crown,  or,  if  the  tooth  is  badly  broken  down,  by  the  shape 
of  the  parts  remaining.  Other  means  of  diagnosis  are:  if,  in 
applying  Standard  forceps  No.  3  R  or  No.  3  L,  secure  adjustment 
cannot  be  had  to  the  buccal  wall,  fusion  of  the  roots  may  be 


164  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

suspected;  or  if,  when  executing  the  extraction  movements, 
imiisnally  firm  resistance  is  encountered,  it  is  a  fair  indication 
that  this  condition  is  present.  Standard  forceps  No.  4  (Fig.  5) 
are  indicated  in  a  case  of  this  character,  and  greater  tractile 
movement  is  permissible  than  for  the  removal  of  roots  that  are 
normal.  If  extraction  cannot  be  completed  with  the  forceps 
without  endangering  the  process  or  possibly  fracturing  the  roots 
by  the  excessive  force  required  to  loosen  the  attachment,  extrac 
tion  movements  should  be  discontinued  and  the  margins  of  the 
process  removed  lingually  and  buccally  with  a  bur,  after  which 
the  forceps  are  reapplied  and  the  extraction  is  completed. 

Where  these  teeth  are  badly  broken  down,  they  can  usually 
be  loosened  by  an  application  of  the  modified  Cryer  elevator 
(Fig.  25)  to  the  mesio-  or  disto-lingual  surface,  following  the 
same  technic  of  operation  as  for  the  use  of  the  elevator  on  the 
superior  molar  (page  167).  When  apply hig  the  elevator,  no  at- 
tempt should  be  made  to  complete  the  extraction  with  it,  using 
only  sufficient  application  to  loosen  the  tooth,  the  extraction 
being  completed  with  the  forceps. 

Occasionally  a  superior  second  molar  is  presented  that  has  the 
three  roots  fused  into  one.  It  is  comparatively  easy  to  extract 
such  root,  as  it  tapers  rapidly  from  a  crown  that  is  excessively 
large  to  be  supported  by  a  single  root  and  terminates  with  a 
blunt  apex. 

Three  Roots  United. — Where  the  entire  crown  has  been  de- 
stroyed by  caries,  the  operator  must  use  careful  judgment  in  the 
technic  of  extraction  he  is  to  employ.  If  the  three  roots  are 
united,  application  is  made  with  Standard  forceps  No.  3  R  or 
No.  3  L  (Figs.  3,  4),  depending  on  which  side  of  the  arch  the 
roots  are  situated,  and  the  extraction  movements  usually  appli- 
cable to  superior  first  and  second  molars  are  executed,  with  the 
difference  that  the  tractile  movement  is  almost  entirely  elimi- 
nated and  the  upward  force  of  application  continued  throughout 
the  operation.  In  most  cases  these  movements  will  suffice  to 
remove  all  the  roots,  but,  if  they  do  not,  they  will  break  up  their 
attachments,  and  usually  one  or  more  will  be  carried  from  their 
socket.  The  remaining  ones,  loosened  by  the  operation,  are 
readily  removed  with  Standard  forceps  No.  2  (Fig.  2).  Where 
the  tooth  to  be  extracted  is  of  irregular  triangular  shape,  as  is 
common  with  the  second  molar,  due  to  its  having  but  two  roots, 


SUPERIOR  FIRST  AND  SECOND  MOLARS  165 

Standard  forceps  No.  4  (Fig.  5)  are  employed,  as  described  in 
the  case  of  fused  roots  (page  163). 

If  one  or  both  of  the  buccal  roots  are  extensively  affected  by 
caries,  Standard  forceps  No.  2  are  used,  applying  one  blade  to 
the  lingual  root  and  the  opposite  one  to  the  mesio-buccal  or  the 
disto-buccal  root,  whichever  is  the  stronger.  Other  conditions 
being  equal,  api^lication  to  the  disto-buccal  and  lingual  root  is 
preferred.  The  roots  are  disengaged  by  a  swaying  movement 
bucco-lingually,  which  will  usually  carry  the  remaining  root 
along  with  the  others,  but,  should  it  not,  it  is  extracted  with  the 
same  forceps,  or,  if  small,  with  Standard  forceps  No.  5  (Fig.  6). 

Two  Roots  United. — Where  the  two  buccal  roots  are  firmly 
united  and  the  lingual  root  is  partially  or  completely  separated 
from  them,  operation  on  the  two  sections  is  performed  separately. 
In  case  separation  is  complete  and  considerable  space  intervenes 
between  the  roots,  the  two  buccal  roots  are  engaged  with  Stand- 
ard forceps  No.  4,  application  being  made  well  up  on  them,  and 
the  principal  extraction  movement  is  executed  buccally.  If, 
however,  the  lingual  root  is  more  accessible,  it  is  extracted  first, 
using  Standard  forceps  No.  2,  which  are  applied  where  there  is 
least  interference,  and  the  root  is  loosened  by  a  right-and-left 
rotatory  motion.  If,  when  extracting  the  two  buccal  roots,  a 
tooth  is  missing  on  either  side  of  the  roots,  application  may  be 
made  to  the  mesial  and  distal  surfaces  instead  of  by  the  usual 
method,  using  Standard  forceps  No.  2,  and  the  roots  carried  in 
the  direction  described  above.  If  either  the  mesio-buccal  and 
lingual  or  the  disto-buccal  and  lingual  roots  are  united,  and  the 
remaining  root  is  separated  from  them,  they  are  all  extracted 
with  Standard  forceps  No.  2,  as  described  for  a  similar  condition 
in  the  case  of  three  roots  united  (page  164). 

Separated  Roots. — Where  all  the  roots  are  separated,  appli- 
cation and  extraction  are  performed  as  if  operating  on  indi- 
vidual teeth,  and  Standard  forceps  No.  2  are  usually  employed. 
The  lingual  root  should  be  extracted  first  if  access  can  be 
obtained,  for,  when  it  is  removed,  application  can  be  more  readily 
made  to  the  buccal  roots.  If,  however,  application  cannot  be 
easily  made  to  the  lingual  root,  then  it  is  made  to  the  most 
accessible  one,  and  the  next  application  is  made  to  the  next  most 
accessible  root.  In  removing  the  buccal  roots,  the  first  and  prin- 
cipal extraction  movement  is  buccally,  while  the  right-and-left 


166  EXTRACTION  TECHNIC  OF  SUPERIOR   TEETH 

rotatory  movement  is  the  principal  one  used  in  breaking  up  the 
attachment  of  the  lingual  root. 

Roots  Covered  by  Gum  Tissue. — Where  the  gum  tissue  covers 
the  broken-down  crown  of  a  superior  first  or  second  molar,  a 
careful  examination  should  be  made  to  ascertain  the  condition 
of  the  underlying  tooth  structure  in  order  to  determine  the 
method  of  operation  that  is  to  follow.  The  diagnosis  having 
been  made,  the  forceps,  if  indicated,  are  applied  in  the  same 
manner  as  described  and  illustrated  for  the  superior  central 
incisor  (page  116),  care  being  exercised  to  open  the  beaks  suffi- 
ciently to  engage  the  entire  area  of  structure  where  the  parts 
are  to  l)e  removed  in  toto.  After  access  has  been  obtained,  the 
extraction  technic  is  the  same  as  for  a  like  condition  where  the 
tooth  is  exposed  to  view.  If,  however,  the  parts  are  so  obscured 
that,  after  irrigating  them  with  an  antiseptic  solution,  a  correct 
diagnosis  cannot  be  made,  it  is  sometimes  permissible  to  apply 
the  forceps  as  though  all  the  roots  were  intact.  If  the  broadest 
linguo-buccal  diameter  has  been  engaged  between  the  beaks,  it 
will  usually  result  in  the  extraction  of  the  roots,  or  at  least  one 
of  them;  and,  if  only  one  has  been  extracted,  the  others  can  be 
taken  out  by  methods  previously  described. 

In  removing  roots  that  are  obscured  by  the  soft  tissues,  an 
examination  should  be  made  of  each  part  extracted  in  order  to 
determine  the  number  of  roots  that  may  be  present,  for,  if  only 
two  roots  are  present,  the  mistake  may  be  made  of  making  a 
third  application  to  some  part  of  the  process. 

Deep-Seated  Roots. — No  attempt  should  be  made  to  make  a 
vigorous  application  of  the  forceps  to  a  deep-seated  root,  expect- 
ing thereby  to  break  down  parts  of  the  alveolar  process  and 
thus  secure  an  adjustment  to  the  root.  As  previously  stated 
(page  158),  alveolar  application  should  never  be  attempted  with 
the  superior  molars  unless  a  careful  examination  shows  that  a 
considerable  portion  of  the  process  is  carious,  and  even  then  it 
should  not  be  attempted  above  the  carious  area.  When  applica- 
tion cannot  be  had  otherwise,  the  procedure  should  be  to  remove 
parts  of  the  process  with  the  cross-cut  fissure  bur,  so  that  the 
forceps  may  be  applied  or  the  elevator  adjusted.  In  extreme 
cases,  where  a  small  part  of  a  root  remains  and  it  is  in  a  patho- 
logic condition,  it  may  be  necessary  to  remove  it  with  a  round 
bur. 


SUPERIOR  FIRST  AND  SECOND  MOLARS  167 

Screw-Porte. — Cases  for  using  a  screw-porte  on  these  teeth  are 
not  numerous.  Its  use  is  indicated  only  where  the  operator  has 
to  remove  a  root  that  is  deeply  seated  and  the  alveolar  structure 
that  surrounds  it  is  heavy,  or  where  the  case  is  of  such  a  nature 
that  the  elevator  will  not  dislodge  the  root,  as  in  hypercemen- 
tosis.     In  such  case  the  Keith  screw-porte  (Fig.  .31)  is  used. 

Elevator. — Some  operators  do  not  favor  the  use  of  the  elevator 
on  the  superior  molars,  but  the  author  has  found  that  there  are 
many  instances  where  the  Cr^^er  elevator  (Fig.  24),  especially 
the  modified  Cryer  (Fig.  25),  can  be  used  advantageously  on 
these  teeth.  If,  when  extracting  a  superior  molar,  one  of  the 
roots  is  so  shaped  that  it  cannot  be  removed  with  the  crown,  its 
attachment  can,  as  a  rule,  be  readily  broken  up  with  the  modified 
Cryer  elevator,  and  removed  from  its  socket  with  the  Derenberg 
tweezers,  which  method  is  better  than  attempting  to  reapply 
the  forceps. 

If,  when  extracting  superior  molar  roots,  the  application  of 
the  forceps  is  difficult,  but  access  can  be  had  with  the  Cryer 
elevator,  application  should  be  made  with  it  to  the  most  accessi- 
ble part  of  the  root,  the  process  or  tooth  in  closest  proximity  is 
engaged  as  the  fulcrum,  and  the  root  is  loosened,  when  its  extrac- 
tion is  completed  with  the  forceps  or  the  Derenberg  tweezers. 

If,  when  extracting  superior  molar  roots,  all  three  are  united, 
it  is  not  infrequent  for  one  or  two  of  the  roots  to  remain,  and 
these  can  often  be  more  readily  removed  with  the  elevator  than 
with  the  forceps.  When  decay  has  advanced  so  far  that  the 
roots  are  not  strongly  united,  they  can  often  be  broken  apart  by 
the  use  of  an  elevator,  which  operation  also  usually  loosens  them 
from  their  attachments. 

If,  when  extracting  a  superior  molar,  the  roots  are  fused  and 
the  crown  considerably  broken  down,  good  results  can  often  be 
had  by  applying  the  modified  Cryer  elevator  to  the  mesio-  or 
disto-lingual  walls  and  breaking  up  the  attachment  before  at- 
tempting to  apply  the  forceps.  When  these  teeth  are  so  badly 
broken  down  and  the  process  so  heavy  that  neither  forceps  nor 
elevator  can  be  applied,  the  procedure  should  be  to  remove  a 
part  of  the  process  with  a  bur  and  apply  the  elevator. 

If,  when  extracting  a  superior  molar,  decay  has  destroyed  a 
considerable  portion  of  the  crown  and  the  approximating  teeth 
have  narrowed  the  space  to  such  an  extent  that  the  tooth  cannot 


168  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

be  taken  out  ^;^  toto,  the  remaining  parts  of  the  crown  should  be 
removed,  the  roots  separated  with  a  cross-cut  fissure  bur,  and 
the  attachment  of  the  roots  broken  up  with  the  Cryer  elevator. 
In  using  the  elevator,  the  blade  is  introduced  between  the  roots, 
one  of  which  is  used  as  a  fulcrum  until  one  or  two  of  the  roots 
have  been  removed,  when  the  most  available  part  of  the  process 
is  used  as  a  fulcrum  to  complete  the  operation. 

Impacted  or  Wedged. — The  superior  first  molar  is  never  im- 
pacted, but  is  sometimes  wedged  between  the  second  bicuspid 
and  second  molar,  due  to  a  partial  or  complete  destruction  of  its 
crown.  When  in  this  condition,  its  extraction  is  accomplished 
in  the  same  manner  as  though  it  were  not  wedged,  provided  this 
can  be  done  without  disturbing  the  tooth  on  eitlier  side  of  it;  but, 
if  this  cannot  be  done,  the  crown  should  be  removed  and  the 
roots  extracted  by  the  technic  of  operation  described  under 
elevator  (page  167).  When  extracting  a  wedged  superior  second 
molar,  the  operative  technic  is  the  same  as  for  a  superior  first 
molar  when  it  is  in  a  similar  condition. 

Impaction  is  not  common  with  the  second  molar,  but  some- 
times occurs,  and,  when  it  is  impacted,  the  third  molar  is  usually 
missing  and  the  crown  of  the  second  molar  engages  the  distal 
wall  of  the  first  molar:  or  the  impaction  may  result  from  heavy 
alveolar  process,  due  to  a  deflection  from  its  normal  position 
while  erupting.  Such  impacted  molar  is  removed  by  the  same 
method  of  operation  as  applies  to  the  superior  third  molar  in  a 
like  condition  (page  179). 

Fracture. — A  fracture  during  the  application  of  the  extraction 
movements  to  a  superior  molar  is  an  accident  that  will  happen 
to  the  most  skilled  operator,  as  it  is  not  always  possible  to  defi- 
nitely judge  the  strength  of  the  tooth  when  it  is  extensively 
attacked  by  caries,  or  to  know  the  firmness  of  its  attachment 
in  the  alveolar  process. 

The  technic  of  the  operation  that  should  follow  a  fracture  will 
depend  entirely  on  the  location  of  the  fracture  and  the  condition 
of  the  remaining  parts.  Whatever  this  condition  may  be,  the 
operation  must  proceed  by  the  method  that  will  best  accomplish 
the  desired  end  and  conserve  the  greatest  amount  of  tissue. 

If  a  reasonable  part  of  the  crown  remains,  the  same  forceps 
are  reapplied  and  the  extraction  movements  continued.  Some- 
times the  fracture  will  show  that  the  margin  of  the  process  is 


SUPERIOR  FIRST  AND  SECOND  MOLARS  169 

carious,  and  at  other  times  the  tooth  will  split  obliquely  upward, 
distally  or  mesially,  so  that  either  the  disto-buccal  or  mesio- 
buccal  root  will  be  nearly  detached  by  the  fracture.  In  either 
case,  Standard  forceps  No.  2  (Fig.  2)  should  be  applied  to  the 
lingual  root  and  to  the  root  most  firmly  united  with  the  lingual, 
and  the  extraction  should  proceed  as  when  the  crown  is  intact. 
If  the  fracture  occurs  well  up  on  the  tooth  lingually,  but 
enough  of  the  tooth  remains  buccally  for  the  application  of  one 
beak  of  the  forceps,  the  method  of  procedure  indicated  is  either 
the  removal  of  the  alveolar  ridge  lingually  and  a  reapplication 
of  the  forceps,  or  a  separating  of  the  lingual  root  from  the  buccal 
roots  with  a  fissure  bur,  in  the  latter  case  the  blade  of  an  elevator 
being  adjusted  between  the  separated  parts  to  break  up  their 
attachments,  as  described  for  tlie  use  of  the  elevator  (page  167). 
The  fracture  may  occur  in  a  reverse  direction,  leaving  sufficient 
structure  lingually  for  the  application  of  the  forceps  and  none 
buccally.  When  this  occurs,  the  marginal  ridge  should  be 
removed  buccally  and  the  forceps  reapplied;  or,  if  the  parts 
remaining  on  either  side  are  too  short  for  a  reapplication,  a 
removal  of  the  marginal  ridge  on  both  sides  is  permissible.  This 
technic  is  indicated  only  where  the  parts  of  the  tooth  that 
remain  are  firm  and  not  weakened  by  decay. 

Where  fracture  occurs  at  a  considerable  distance  above  the 
process  both  lingually  and  buccally,  and  the  forceps  or  the  ele- 
vator cannot  be  applied  without  the  removal  of  quite  a  portion 
of  the  process,  the  roots  should  be  separated  from  each  other 
with  the  fissure  l)ur,  their  attachments  broken  up  by  introducing 
the  elevator  between  them,  and,  when  loosened,  removed  with 
Standard  forceps  No.  2. 

Where  fracture  has  occurred  in  the  case  of  a  superior  molar 
that  has  only  two  roots,  the  fused  root  may  be  very  broad,  with 
a  groove  extending  down  each  side.  Where  this  condition  exists, 
it  may  require  quite  an  effort  to  entirely  separate  the  root  with  a 
bur,  but,  if  separated  for  a  considerable  distance,  the  separation 
may  be  completed  by  the  use  of  a  heavy  enamel  chisel.  The 
extraction  is  completed  by  loosening  the  roots  with  the  Cryer 
elevator  and  removing  them  with  the  forceps  or  Derenberg 
tweezers. 

If  fracture  occurs  so  far  l)eyond  the  neck  of  the  tooth  as  to 
nearly  separate  the  roots,  they  are  broken  apart  by  the  applica- 


170  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

tion  of  the  Cryer  elevator.  The  roots  are  then  extracted  by 
introducing  the  elevator  on  the  distal  side  of  the  disto-buccal 
root,  using  the  process  as  a  fulcrum  to  remove  it,  and  after  its 
removal  a.  mesial  application  to  the  mesio-buccal  root  in  the  same 
manner  will  usually  dislodge  it,  as  the  space  caused  by  the 
removal  of  the  disto-buccal  root  will  greatly  aid  in  the  extrac- 
tion of  the  mesio-buccal  root. 

Where  a  fracture  occurs,  and  one  root  leaves  the  socket  intact 
with  the  crown,  but  one  or  two  roots  remain,  the  latter  may  be 
removed  with  the  Cryer  elevator. 

Maxillary  Sinus. — In  all  operations  on  the  roots  of  deep-seated 
superior  hrst  and  second  molars,  whether  applying  forceps  or 
elevator,  pressure  must  not  be  exerted  upward  on  them,  as 
the  floor  of  the  maxillary  sinus  may  be  situated  immediately 
above  their  apices.  This  jn-ecaution  must  be  especially  observed 
with  the  buccal  roots  of  the  superior  first  molar,  whose  apices 
often  form  convolutions  in  the  floor  of  the  sinus.  If  the  opera- 
tor is  in  doubt  as  to  the  existing  conditions  when  operating,  he 
should  carefully  flush  out  the  sockets  with  warm  sterilized  water 
before  further  procedure  and  make  a  thorough  examination,  as 
a  little  precaution  may  obviate  serious  trouble. 

SUPERIOR  THIRD  MOLAR. 

The  extraction  of  the  su]:>erior  third  molar  is  indicated  almost 
as  frequently  as  that  of  the  inferior  third  molar,  and  Fig.  80 
shows  the  various  types  of  third  molars  that  are  usually  seen. 
Abnormalities  of  the  crown  and  roots  of  this  tooth  are  not  un- 
common, and  Fig.  81  shows  various  types  of  these  abnormalities. 
As  may  be  noted,  this  tooth  varies  both  in  the  size  and  shape  of 
its  crown.  Occasionally  the  crown  is  of  about  the  same  size 
as  the  crown  of  a  normal  second  molar,  and  may  vary  from  this 
size  down  to  one  only  a  few  lines  in  any  of  its  transverse 
diameters.  In  shape  it  will  vary  from  the  imperfect  rhombic 
form  of  the  second  molar,  through  all  the  variations  in  the  shape 
of  this  tooth,  to  the  imperfect  cylindrical  form  peculiar  only  to 
this  tooth  and  supernumerary  teeth. 

Where  the  eruption  of  this  tooth  is  obstructed,  the  condition 
does  not  cause  the  great  amount  of  distress  that  usually  accom- 
panies a  similar  condition  of  the  inferior  third  molar.  The 
resistance  to  its  eruption  by  the  hard  tissue  is  not  so  great  as 


SUPERIOR  THIRD  MOLAR 


171 


Fig.   SO.— Types  of  superior   third  molars.     The   first   row  shows   the  Iniceal,   the  second 
row  the  lingual,  the  third  row  the  mesial,  and  the  fourth  row  the  distal  surface. 


172  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

with  the  inferior  third  molar,  and  the  superior  third  molar,  if  it 
erupts  in  malposition,  usually  inclines  to  the  buccal  side  of  the 
arch  or  posteriorly. 

Position  of  Patient  and  Operator.^The  position  of  the  patient 
in  the  chair  and  that  of  the  operator  is  as  described  for  extract- 
ing superior  teeth  (page  93).  In  some  cases,  however,  where 
the  tooth  is  obscured  by  displacement  or  other  interference, 
better  access  to  it  can  be  had  by  raising  the  chair  until  the  head 
of  the  patient  is  slightly  above  the  shoulders  of  the  operator. 

When  operating  on  either  the  left  or  right  side  of  the  arch, 
the  head  of  the  patient  as  well  as  the  position  of  the  arm  of  the 
operator  and  the  arrangement  of  the  hand  and  fingers  are  the 
same  as  described  for  the  first  and  second  molars  (page  154), 
except  that  the  position  of  the  fingers  is  a  little  more  posterior 
and  the  raising  of  the  lip  is  done  principally  at  the  corner  of 
the  mouth. 

The  mouth  should  seldom  be  opened  to  its  fullest  extent,  and 
especially  should  this  not  be  done  if  the  mouth  is  small,  the 
patient  is  fleshy,  or  the  tooth  is  displaced  buccally.  In  opening 
the  mouth  to  the  fullest  extent,  the  ramus  and  coronoid  process  of 
the  mandible  are  drawn  down  past  the  third  molar  and  in  close 
proximity  to  that  tooth.  This  not  only  obscures  the  view  of  the 
tooth,  but  interferes  with  the  application  of  the  forceps  and 
prevents  the  proper  execution  of  the  extraction  movements. 
Opening  the  mouth  about  two-thirds  of  its  full  extent  will 
usually  allow  the  best  access  to  this  tooth,  and  the  operator's 
position  at  the  chair  should  be  such  that  he  has  a  good  view  of 
the  tooth  throughout  the  operation. 

Forceps. — Standard  forceps  No.  4  (Fig.  5)  are  usually  employed 
in  the  extraction  of  this  tooth.  If  the  tooth  is  normally  devel- 
oped and  has  three  roots.  Standard  forceps  No.  3  R  and  No.  3  L 
(Figs.  3,  4)  may  be  used;  and  if  it  is  small  or  conical-shaped, 
Standard  forceps  No.  2  (Fig.  2)  should  be  used. 

Order  of  Extraction.— The  extraction  of  this  tooth  should,  as 
a  rule,  precede  that  of  the  second  molar,  and,  in  fact,  where  a 
number  of  teeth  are  to  be  extracted  from  different  parts  of  the 
superior  arch  at  the  same  sitting,  if  conditions  are  favorable,  the 
third  molar  should  always  be  extracted  first.  The  rule  is  re- 
versed only  where  the  tooth  is  impacted  or  difficult  to  remove, 
and  where  the  second  molar  is  also  to  be  extracted  and  its 


SUPERIOR  THIRD  MOLAR 


173 


Fig.  81.— Types  of  abnormal  superior  third  molars.  Ttie  tirst  and  second  rows  show 
four-rooted  teeth,  the  third  row  shows  teeth  with  roots  that  are  fused,  the  lourtn 
row  shows  teeth  having  crowns  with  a  single  cone  and  only  one  root,  and  the 
fifth  row  shows  teeth  having  roots  in  which  there  is  great  variation  in  term. 


174  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

removal  will  simplify  access  to  the  third  molar.  Where  both 
of  the  superior  third  molars  are  to  be  extracted,  the  one  on  the 
left  side  is  removed  before  the  one  ou  the  right  side. 

Application  of  Forceps. — Securing  a  good  adjustment  of  the 
forceps  to  this  tooth  is  often  virtually  the  completion  of  the  oper- 
ation, as  frequently  its  roots  are  so  shaped  that  the  tooth  leaves 
the  socket  on  the  initial  application.  The  forceps  having  been 
selected,  the  lingual  beak  should  be  adjusted  first  and  then  the 
buccal  beak,  provided  that  access  to  the  tooth  is  readily  obtained. 
If,  however,  the  tooth  is  hidden  by  the  soft  tissues  toward  the 
buccal  side,  it  will  be  advisable  to  make  the  adjustment  to  the 
buccal  side  first.  In  applying  the  forceps,  the  operator  should 
avoid  engaging  the  tuberosity  posterior  to  this  tooth  or  the  gum 
tissue,  the  latter  sometimes  being  unusually  heavy  about  the 
tooth. 

Alveolar  Application  of  Forceps. — As  with  the  two  molars 
anterior  to  it,  the  alveolar  application  should  not  be  attempted 
with  the  superior  third  molar  when  the  process  surrounding  it 
is  not  diseased.  Where  the  process  is  carious,  slight  alveolar 
application  is  permissible,  but  should  be  made  with  care,  as  there 
is  always  danger  of  fracturing  the  tuberosity,  especially  if  the 
latter  is  prominent.  Wherever  it  is  necessary  to  secure  an  ad- 
justment of  the  forceps  above  the  margin  of  the  alveolus,  re- 
moving a  part  of  the  process  with  a  bur  is  a  safer  course  to 
pursue. 

Extraction  Movements. — ^When  Standard  forceps  No.  4  (Fig.  5) 
have  been  adjusted  to  a  superior  third  molar  (Fig.  82,  A),  and 
this  adjustment  has  not  loosened  or  dislodged  the  tooth,  it  is 
carried  buccally  with  a  degree  of  force  varying  with  the  strength 
of  the  tooth  and  the  resistance  to  be  overcome  (Fig.  82,  B).  In 
most  instances  this  will  release  the  tooth,  when  it  is  carried  from 
its  socket  by  a  tractile  movement  downward  in  a  line  usually 
buccally  of  the  median  line  of  the  ridge. 

Where  the  roots  are  considerably  spread,  more  resistance  will 
be  encountered,  and  in  such  case  the  operator  must  proceed 
cautiously  to  avoid  fracturing  the  tooth  or  the  tuberosity.  Wlien 
the  buccal  movement  does  not  break  up  the  attachment,  the 
tooth  is  carried  back  lingually  and  carefully  swayed  back  and 
forth  until  its  attachment  is  broken  up,  when  it  is  carried  from 
its  socket  in  the  direction  of  least  resistance.     When  necessary. 


SUPERIOR   THIRD  MOLAR 


175 


some  force  downward  may  be  exerted  in  executing  the  tractile 
movement. 

The  two  buccal  roots  of  this  tooth  will  on  rare  occasions  be 
divergent,  the  mesio-buccal  root  inclining  mesially  and  the  disto- 
buccal  inclining  distally.  In  such  case  the  removal  of  a  small 
area  of  the  buccal  plate  of  the  alveolus  with  the  tooth  is  unavoid- 
able. Where  this  condition  is  observed,  to  avoid  such  an  acci- 
dent, the  extraction  movements  should  be  discontinued,  and  the 
alveolus  removed  from  the  buccal  wall  of  the  tooth  before  com- 
pleting the  extraction. 


B 


Fig.  82. — Extraction  movements  for  superior  third  molar.     A,  forceps  (Standard  No.  4) 
applied;  B,  extraction  movement  to   the  buccal  side. 

The  fusion  of  all  the  roots  into  one  is  very  common  with  the 
superior  third  molar,  and,  where  this  condition  exists,  its  extrac- 
tion is  usually  a  very  simple  matter.  The  application  of  the 
forceps,  with  a  slight  pressure  on  the  beaks,  will  usually  cause 
the  tooth  to  leave  its  socket,  and  it  will  often  slip  down  between 
the  beaks  of  the  forceps  so  suddenly  that  the  operator  will  think 
he  has  produced  a  fracture. 

In  any  operation  on  the  superior  third  molar,  the  tuberosity 
should  be  considered,  and  during  any  application  to  this  tooth 


176  EXTRACTIOX  TECHNIC  OF  SUPERIOR  TEETH 

the  slightest  movement  of  the  tuberosity  should  be  taken  into 
account.  Eather  than  endanger  the  tuberosity  with  a  possible 
fracture,  it  will  be  better  to  discontinue  the  operation  and  remove 
a  portion  of  the  process  from  about  the  tooth  with  a  bur.  Where 
the  superior  third  molar  has  been  isolated  for  some  time,  the 
attachment  of  the  tooth  is  usually  more  firm,  and  greater  care 
should  be  observed  in  its  extraction  than  if  the  teeth  in  front  of 
it  are  in  position.  In  some  mouths  the  gum  tissue  is  yerj  heavy 
on  the  lingual  side  of  the  tooth,  or  the  entire  crown  of  the  tooth 
may  be  deeply  seated  in  the  soft  tissues,  and,  where  this  condi- 
tion exists,  care  should  be  taken  that  the  tissue  is  not  lacerated 
during  the  extraction. 

Displacement. — This  tooth  is  out  of  alignment  more  frequently 
than  any  other  superior  tooth,  and  is  usually  displaced  to  the 
buccal  side  of  the  arch.  Where  displaced  in  any  other  direction, 
the  displacement  is  so  slight  that  the  technic  of  oioeration  is  the 
same  as  for  a  tooth  in  normal  occlusion. 

Where  this  tooth  is  displaced  buccally,  the  displacement  will 
vary  from  a  very  slight  displacement  to  a  complete  eruption  on 
the  buccal  side  of  the  alveolar  process,  with  the  occlusal  surface 
directed  toward  the  cheek.  Where  the  tooth  is  displaced  in 
this  manner,  the  greatest  difficulty  in  its  extraction  will  be  to 
secure  an  adjustment  of  the  forceps.  Where  access  can  be  had, 
Standard  forceps  No.  4  (Fig.  5)  should  be  used,  and,  if  access 
is  difficult,  Standard  forceps  No.  2  (Fig.  2)  are  substituted.  If 
possible,  the  adjustment  is  made  in  the  usual  manner,  but,  if  this 
cannot  be  done,  the  order  of  application  of  the  beaks  is  reversed. 
The  forceps  having  been  applied,  the  tooth  is  extracted  by 
movements  executed  as  nearly  as  possible  as  those  given  for 
extracting  the  same  tooth  in  normal  occlusion  (page  174). 

Caries. — Where  the  superior  third  molar  is  extensively  involved 
with  caries  on  its  mesial  or  distal  surface,  application  and  ex- 
traction is  performed  with  Standard  forceps  No.  4  if  good  adap- 
tation can  be  had;  but  where  caries  is  very  extensive,  and  the 
part  remaining  is  rather  firm,  better  execution  can  usually  be 
accomplished  by  the  use  of  Standard  forceps  No.  2. 

Gingival  Caries. — Caries  on  the  buccal  surface  of  the  superior 
third  molar,  extending  around  and  al)ove  the  gum  margin,  is 
very  common.  Where  the  decay  is  of  considerable  extent,  one 
beak  of  the  forceps  is  sent  up  quite  a  distance  and  with  some 


SUPERIOR  THIRD  MOLAR  177 

force  on  the  lingual  surface  of  the  tooth,  and  the  opposite  beak 
is  carefully  adjusted  to  the  buccal  surface  so  as  to  cover  as  much 
of  this  surface  as  possible,  but  no  attempt  is  made  to  send  it 
excessively  high  on  this  side.  The  forceps,  when  being  applied, 
should  not  impinge  forcibly  on  the  tissues  of  the  cheek.  Extrac- 
tion is  obtained  by  the  usual  movement  buccally  (page  174). 

Gingival  decay  is  not  frequent  on  the  lingual  surface  of  this 
tooth,  and,  when  present,  the  removal  does  not  differ  from  the 
usual  extraction  of  the  tooth,  care  being  taken  that  good  adjust- 
ment of  the  forceps  is  had  to  its  lingual  side. 

Three  Roots  United. — AVhere  the  crown  is  destroyed  by  caries 
and  the  roots  are  left  united,  the  roots  are  often  fused,  and 
when  in  this  condition  are  generally  dislodged  by  the  initial 
application  of  the  forceps.  If  the  parts  are  of  considerable  size, 
Standard  forceps  No.  4  (Fig.  5)  should  be  used,  applying  the 
same  extraction  movements  as  when  the  crown  is  intact 
(page  174).  If  the  remaining  parts  are  small,  adjustment  is 
made  preferably  to  the  lingual  and  mesio-buccal  surfaces  with 
Standard  forceps  No.  2  (Fig.  2),  and  the  roots  carried  out 
toward  the  buccal  side.  In  most  of  these  cases  the  beaks  should 
be  sent  well  up  on  the  roots  for  a  firm  adjustment,  but  this  must 
be  done  very  cautiously,  as  the  process  is  never  very  heavy  in 
this  region,  and  no  great  amount  of  force  is  required  to  effect 
this  adjustment.  If,  after  the  initial  extraction,  one  of  the  roots 
remains,  it  is  extracted  with  Standard  forceps  No.  2  (Fig.  2)  or 
No.  5  (Fig.  6)  by  a  rotatory  movement. 

Two  Roots  United. — With  superior  third  molar  roots  not  many 
cases  occur  where  two  roots  are  intact  and  one  is  isolated. 
Where  this  condition  exists,  Standard  forceps  No.  2  should  be 
adjusted  to  whichever  two  roots  are  united,  and  they  are  ex- 
tracted by  the  usual  movements.  Their  extraction  will  usually 
loosen  the  remaining  root,  but,  if  it  does  not,  it  is  extracted  with 
the  same  forceps,  or,  if  small,  with  Standard  forceps  No.  5. 

Separated  Roots. — Where  the  roots  of  this  tooth  are  separated, 
Standard  forceps  No.  2  should  be  used  if  the  roots  are  of  con- 
siderable size;  but  if  they  are  small.  Standard  forceps  No.  5  are 
employed.  The  extraction  of  these  roots  is  performed  by  ad- 
justing the  forceps  to  the  most  accessible  root  first  and  releasing 
it  by  a  rotatory  movement.  This  movement  is  applied  to  a  ma- 
jority of  superior  third  molar  roots,  but  where  a  root  is  flattened 


178  EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 

it  is  loosened  with  the  linguo-buccal  movement.  Where  decay  is 
extensive,  the  application  of  the  modified  Cryer  elevator  (Fig.  25) 
is  made  to  the  mesio-buccal  root,  using  the  second  molar  or  the 
process  as  a  fiilcriim,  and,  when  loosened,  it  is  extracted  with 
forceps  or  Derenberg  tweezers.  The  same  technic  is  applicable 
to  the  palatal  root.  The  disto-buccal  root  is  disengaged  by 
applying  the  elevator  to  its  distal  surface  and  forcing  it  mesially. 

Roots  Covered  by  Gum  Tissue. — Where  the  broken-down  parts 
of  the  superior  third  molar  are  covered  by  the  soft  tissue,  an 
examination  of  the  parts  should  be  made  to  ascertain  the  original 
size  of  the  tooth  and  the  amount  of  its  structure  remaining.  If 
the  tooth  is  of  considerable  size,  Standard  forceps  No.  4  are 
used,  but,  if  small,  better  application  is  had  with  Standard 
forceps  No.  2. 

It  is  seldom  necessary  to  lance  the  tissue  over  the  tooth,  and 
application  should  be  made  as  described  and  illustrated  in  the 
case  of  the  superior  central  incisor  (page  11(5).  Severing  the 
tissue  over  this  tooth  with  the  lancet  is  not  advised,  as  the 
attending  hemorrhage  usually  so  obscures  the  parts  that  it  is 
difficult  to  proceed  with  the  operation.  Lancing  the  gum  is 
indicated  only  where  the  tissue  covering  the  structure  is  so  firm 
or  so  adherent  to  the  tooth  that  it  cannot  be  severed  with  the 
blades  of  the  forceps.  After  application  has  been  obtained,  the 
technic  of  extraction  is  the  same  as  for  removing  roots  of  this 
tooth  unobscured  when  in  a  like  condition  of  decay. 

Deep-Seated  Roots. — When  the  remaining  roots  of  the  superior 
third  molar  are  deeply  seated,  great  care  in  operating  on  them 
should  be  exercised  to  avoid  a  fracture  of  the  tuberosity.  The 
technic  of  operation  does  not  differ  materially  from  that  on 
the  roots  of  superior  first  and  second  molars  when  in  a  like 
condition. 

Elevator. — The  number  of  cases  for  the  application  of  the 
elevator  to  the  superior  third  molar  is  limited,  and  no  attempt 
should  be  made  to  apply  this  instrument  when  the  crown  is 
intact,  or  the  tooth  is  in  normal  alignment,  or  the  tuberosity  is 
of  considerable  size,  as  it  is  seldom  practicable  to  force  this  tooth 
posteriorly  as  a  preliminary  to  applying  forceps.  The  elevator 
can  be  appropriately  applied,  if  judiciously  used,  to  a  tooth  that 
is  impacted  and  displaced  buccal ly,  or  to  one  impinging  below 
the  crown  of  the  second  molar,  but  only  in  the  capacity  of  slightly 


SUPERIOR  THIRD  MOLAR 


179 


loosening'  the  tooth.  The  elevator  can  be  employed  also  on  the 
mesio-bnceal  root  of  a  third  molar  where  only  this  root  remains. 
Where  the  forceps  cannot  be  ajjplied  to  the  disto-bnccal  root  in 
a  case  where  the  mesial  root  has  been  removed,  the  disto-bnccal 
root  may  be  bronght  mesially  with  an  elevator,  but  never  dis- 
tally.  Careful  judgment  is  necessary  in  the  use  of  the  elevator 
on  the  third  molar. 

Impaction. — The  superior  third  molar  is  not  so  frequently 
impacted  as  the  inferior  third  molar,  and,  when  impacted,  it  is 
not  so  firmly  attached,  nor  does  it  assume  such  inaccessible  posi- 
tions, as  is  common  with  the  latter  tooth.  When  a  pathologic 
condition  ensues  as  a  result  of  the  impaction,  the  inflammatory 


Fig.  83. — Impacted  superior  third  molar.  Radiograph  shows  the  eruption  of  the  tooth 
retarded  by  the  crown  of  the  second  molar  a  short  distance  from  its  normal 
position. 


conditions  in  the  vicinity  of  the  superior  third  molar  are  seldom 
as  acute  or  as  extensive  as  in  the  case  of  the  inferior  third 
molar. 

Partial  Gingival  or  Alreolar. — Where  this  tooth  is  partially 
impacted  by  the  gum  tissue,  the  operator  may  be  led  to  believe 
that  the  tooth  to  be  removed  is  small  or  that  it  is  a  supernu- 
merary tooth,  but  on  the  attempted  application  of  the  forceps  a 
fully  developed  tooth  is  encountered.  Little  attention  should  be 
given  to  the  heavy  tissue  covering  the  tooth,  provided  the  for- 
ceps can  be  securely  adjusted  to  the  tooth  without  lacerating 
this  tissue,  for,  once  the  forceps  are  adjusted,  the  tooth  can 
usually  be  removed  as  readily  as  one  completely  erupted. 

If  a  part  of  the  crown,  in  addition  to  being  covered  by  the 
gum  tissue,  is  covered  by  the  alveolar  process,  the  latter  should 


180 


EXTRACTION  TECHNIC  OF  SUPERIOR  TEETH 


be  removed  with  a  round  bur  over  the  occhisal  surface  of  the 
tooth  and  with  a  cross-cut  fissure  bur  along  its  buccal  and  palatal 
walls,  after  which  Standard  forceps  No.  2  (Fig.  2)  are  adjusted 
and  the  tooth  removed  by  the  usual  technic.  If,  during  the  oper- 
ation, any  movement  of  the  tuberosity  is  observed,  a  part  of  the 
process  distally  should  be  removed  with  a  bur  before  attempting 
to  complete  the  extraction.  If  the  tooth  is  only  slightly  impacted 
(Fig.  83),  the  extraction  may  often  be  completed  with  Standard 
forceps  No.  2  by  the  usual  methods  without  removing  any  of 


Fig.  84. — Impacted  superior  third  molar.     Radiograpli  shows  the  crown  of  the  tooth 

inclining  distally. 


the  process.  The  extraction  movements  are  the  same  whether 
the  tooth  is  displaced  lingually  or  buccally,  or  in  normal  occlu- 
sion. 

An  occasional  form  of  impaction  of  this  tooth  is  seen  where 
its  crown  lies  below  that  of  the  second  molar  and  is  inclined 
distally  (Fig.  84).  In  such  case  it  is  necessary  to  make  an 
incision  of  the  gum  tissue  over  the  crown  with  the  lancet  and 
apply  Standard  forceps  No.  2.  When  the  forceps  are  adjusted, 
the  tooth  is  directed  slightly  distally,  if  the  tuberosity  will  per- 


SUPERIOR  THIRD  MOLAR 


181 


mit  it,  in  addition  to  the  buccal  movement.     A¥lien  the  tooth  has 
been  loosened,  the  delivery  is  made  in  line  with  its  axis. 

Complete  Alveolar. — An  abnormality  of  not  very  frequent 
occurrence  is  that  of  a  superior  third  molar  completely  imbedded 
in  the  alveolus,  with  the  crown  in  an  almost  horizontal  position 
(Fig.  85).  Where  the  tooth  is  impacted  in  this  manner,  its  posi- 
tion is  usually  to  the  buccal  side  of  the  arch.  Where  such  a 
condition  is  presented,  a  radiograph  of  the  parts  should  be  ob- 
tained in  order  that  a  definite  outline  of  the  tooth  and  its  rela- 


Flg.  85. — Impacted  superior   third  molar.     Radiograph 

position. 


shows  the   tooth  in  a  horizontal 


tiou  to  the  surrounding  tissues  may  be  had.  After  gaining 
the  desired  information  from  the  radiograph,  an  incision  should 
be  made  in  the  gum  tissue  and  the  process  covering  the  crown 
carefully  dissected  away.  The  modified  Cryer  elevator  (Fig.  25) 
is  adjusted  to  the  mesio-buccal  surface  of  the  crown  with  suffi- 
cient pressure  to  engage  the  tooth  with  the  point  of  the  instru- 
ment, and  a  pulling  force  is  applied  occluso-buccally,  repeated 
application  being  made  until  it  is  entirely  disengaged.  No  pres- 
sure should  be  applied  distally,  nor  should  a  too  forcible  appli- 
cation be  made  in  any  direction.     It  is  better  to  remove  more  of 


182  EXTRACTION  TECHNIC  OF  SUPERIOR   TEETH 

the  process  than  to  endanger  the  parts  by  attempting  to  extract 
the  tooth  by  force  alone. 

By  Approximatinfj  Tooth. — Where  the  crown  of  the  superior 
third  molar  is  directed  below  the  normal  contact  point  of  the 
crown  of  the  second  molar,  a  radiograph  should  be  obtained 
before  attempting  to  operate  in  order  that  the  development  of 
the  third  molar  and  the  amount  of  its  impaction  be  ascertained. 
If  the  radiograph  shows  that  the  amount  of  impaction  is  not 
extensive  and  that  the  third  molar  is  small,  Standard  forceps 
No.  2  (Fig.  2)  are  adjusted.  The  tooth  is  lirst  carried  cautiously 
toward  the  buccal  side  of  the  arch,  then  back  slightly  to  the 
lingual  side,  and  again  with  increased  force  to  the  buccal  side. 
These  movements  are  continued  until  the  tooth  is  released  from 
its  attachment,  when  it  is  carried  from  its  socket  buccally. 

If  the  operator  finds  that  the  tooth  cannot  be  extracted  without 
fracturing  it  or  endangering  the  tuberosity,  the  operation  should 
be  discontinued  and  enough  process  removed  to  allow  the  tooth 
to  be  released  from  its  impacted  position.  If  it  is  impossible  to 
secure  a  good  application  with  the  forceps,  the  modified  Cryer 
elevator  may  be  inserted  into  the  available  interproximal  space, 
being  applied  to  the  lingual  or  buccal  side,  and  rotated  suffi- 
cientlj^  to  loosen  the  tooth,  when  its  extraction  is  completed  with 
the  forceps.  No  attempt  should,  however,  be  made  to  complete 
the  extraction  with  the  elevator,  as  that  would  endanger  the 
tuberosity. 

If  impaction  is  so  complete  that  the  tooth  cannot  be  removed 
without  the  destruction  of  consideral)le  process,  the  part  of  the 
crown  in  contact  with  the  second  molar  should  be  cut  away  with 
a  carburundum  stone  or  the  fissure  Inir  before  attempting  to 
remove  the  tooth. 

Fracture. — If  the  superior  third  molar  is  fractured  while 
attempting  to  remove  it,  due  to  the  operator  misjudging  the 
extent  to  which  it  is  decayed,  or  due  to  his  failure  to  secure  a 
good  application  of  the  forceps  because  of  its  posterior  location, 
the  forceps  may  be  reapplied,  if  sufficient  structure  remains, 
before  hemorrhage  has  obscured  the  parts.  Where  the  fracture 
is  so  far  beyond  the  neck  of  the  tooth  that  the  forceps  cannot  be 
reapplied,  a  part  of  the  process  on  the  buccal  and  palatal  side 
should  be  removed  with  a  bur.  Standard  forceps  No.  2  applied, 
and  the  tooth  removed  by  the  usual  movement  buccally. 


SUPERIOR  THIRD  MOLAR  183 

If,  after  a  fracture,  the  remaining  part  of  the  tooth  is  slightly 
detached  or  is  not  very  large,  and  the  alveolus  on  the  buccal  side 
interferes  with  the  reapplication  of  the  forceps,  the  modified 
Cryer  elevator  is  applied  to  its  mesial  surface  with  only  sufficient 
pressure  to  loosen  it.  When  loosened,  the  part  is  engaged  with 
Standard  forceps  No.  2  and  removed.  Care  must  be  taken  not 
to  lacerate  the  soft  tissues  nor  engage  the  process  with  the 
forceps. 

If  one  or  two  roots  remain,  and  they  are  lingual  or  mesio- 
buccal,  they  are  released  with  the  modified  Cryer  elevator. 
Access  is  facilitated  by  employing  the  mouth  mirror  and  holding 
the  elevator  as  when  using  an  excavator  in  removing  decay  from 
a  disto-occlusal  cavity  in  this  tooth.  In  most  cases  this  method 
of  applying  the  elevator  will  be  found  very  practicable,  and  will 
obviate  the  necessity  of  reapplying  the  forceps. 

If  only  the  small  tip  of  a  root  remains  and  it  is  not  involved 
in  any  pathologic  condition,  no  attempt  should  be  made  for 
its  removal,  as  usually  it  will  not  cause  any  trouble.  If  the  tip, 
however,  subsequently  causes  any  inconvenience,  it  will  occur  at 
a  time  sufficiently  remote  from  the  operation  that  its  removal 
will  be  very  much  simplified  by  the  al)sorption  of  the  process 
that  has  in  the  meantime  taken  place  on  account  of  the  loss  of 
the  tooth. 


CHAPTER  X. 
EXTRACTION  TECHNIC  OF  THE  INFERIOR  TEETH. 

The  extraction  of  the  inferior  teeth  is,  as  a  rnle,  more  compli- 
cated than  that  of  the  superior  teeth.  Forceps  are  not  so  freely 
used  on  the  inferior  teeth,  and  the  judicious  use  of  the  elevator  is 
advocated  wherever  its  application  is  practicable.  An  operation 
on  the  inferior  third  molar,  which  is  one  of  the  most  difficult 
teeth  to  extract,  becomes  more  complicated  when  this  tooth  is 
impacted.  In  order  that  the  operation  in  the  case  of  an  im- 
pacted inferior  third  molar  may  be  more  clearly  differentiated 
from  an  operation  on  this  tooth  when  not  impacted,  a  separate 
chapter  has  been  prepared  on  the  extraction  technic  of  impacted 
inferior  third  molar  (Chapter  XI). 

INFERIOR  INCISORS. 

The  inferior  incisors  are  extracted  less  frequently  than  any 
other  teeth,  except  the  inferior  cuspids,  and,  when  their  extrac- 
tion is  indicated,  it  is  as  often  caused  by  recession  of  the  sup- 
porting tissues  or  pyorrhea  alveolaris  as  by  tooth  decay.  They 
are  not,  however,  immune  from  caries,  and  when  once  attacked 
by  it  the  progress  is  usually  rapid  and  difficult  to  control. 

The  inferior  incisors — two  centrals  and  two  laterals — are  so 
nearly  alike  in  form  and  attachment,  and  their  surrounding 
tissues  are  so  similar,  that  the  technic  of  extraction  applicable 
to  one  of  them  is  with  very  little  variation  applicable  to  all. 
Fig.  86  shows  the  various  types  of  inferior  incisors  that  are 
usually  seen. 

Position  of  Patient  and  Operator. — The  operator  assumes  the 
position  described  for  extracting  inferior  teeth  (page  96).  The 
position  of  the  head  of  the  patient  is  straight  in  the  head-rest. 
The  left  arm  of  the  operator  is  placed  to  the  left  side  of  the 
head  of  the  patient,  with  the  palm  of  the  hand  over  the  left 
cheek.  The  index  linger  is  inserted  in  the  oral  cavity  on  the 
lingual  side  of  the  anterior  teeth ;  the  second  finger  depresses  the 

184 


INFERIOR  INCISORS 


185 


Fig.  86.— ^Types  of  inferior  central  and  lateral  incisors.  The  first  row  shows  the  labial, 
the  second  row  the  lingual,  the  third  row  the  mesial,  and  the  fourth  row  the  distal 
surface. 


186 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


lower  lip,  exposing  the  field  of  operation;  the  third  and  fourth 
fingers  are  placed  beneath  the  chin  to  support  the  lower  jaw, 
and  they  must  not  be  removed  during  the  extraction,  as  a  very 
slight  movement  of  the  mandible  may  prevent  a  successful  appli- 


Fig.  87. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  an  inferior  incisor.  Illustration  shows  the  application  of  forceps  (Stand- 
ard No.  6)  to  the  inferior  right  central  incisor. 


cation  of  the  forceps  or  a  proper  execution  of  the  extraction 
movements. 

Fig.  87  shows  the  method  of  applying  Standard  forceps  No.  6, 
and  Fig.  88  shows  the  method  of  applying  Standard  forceps 
No.  9.    Either  of  these  methods  gives  the  operator  direct  access, 


INFERIOR  INCIS0R8 


187 


and  the  fingers  placed  as  shown  render  them  instantly  available 
for  ejecting  the  extracted  tooth  from  the  mouth  in  case  the  for- 
ceps lose  control  of  it. 

Forceps. — Standard  forceps  No.  6   (Fig.  7)  are  usually  em- 


Fig.  88.— Position  of  tlie  operator's  hands  and  disposition  of  the  fingers  when  api)lynis 
forceps  to  an  inferior  incisor.  Illustration  shows  the  application  of  forceps  (Stand- 
ard No.  9)   to  the  inferior  right  central  incisor. 

ployed  for  the  removal  of  all  inferior  incisors,  and  are  well  suited 
for  the  extraction  of  these  teeth,  provided  they  are  of  fair  size 
and  in  normal  alignment  in  the  arch.  Equally  satisfactory  re- 
sults can  be  had  also  with  Standard  forceps  No.  8  (Fig.  9),  and, 
if  on  account  of  any  abnonnal  condition  of  mouth,  arch,  or  teeth, 


188  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

good  access  cannot  be  obtained  with  Standard  forceps  No.  6,  the 
use  of  Standard  forceps  No.  8  is  indicated.  For  teeth  that  are 
small,  crowded,  or  irregular.  Standard  forceps  No.  9  (Fig.  10) 
are  used,  which  are  a  counterpart  of  Standard  forceps  No.  8, 
but  with  narrower  beaks.  In  fact,  Standard  forceps  No.  8  and 
No.  9  are  better  adapted  for  the  removal  of  a  majority  of  inferior 
incisors  than  Standard  forceps  No.  6. 

A  liberal  use  of  Standard  forceps  No.  8  and  No.  9  is  recom- 
mended, not  only  for  the  extraction  of  the  incisors,  but  for  all 
the  ten  anterior  inferior  teeth,  as  they  are  invaluable  instruments 
in  the  hands  of  a  skilled  operator  for  the  removal  of  many  of  these 
teeth  where  application  is  difficult  or  impossible  with  any  other 
forceps.  Every  operator  should,  therefore,  master  the  technic  of 
their  use,  which  may  seem  difficult  at  first,  but  is  in  reality  readily 
acquired.  The  basic  principle  of  a  correct  design  in  forceps  is 
that,  when  application  is  made,  tooth,  beaks,  and  handles  are  all 
in  the  same  plane,  and  that,  when  the  power  is  applied  with  the 
hand,  the  tooth  can  be  brought  from  its  socket  also  in  the  same 
plane  without  impinging  on  the  other  tissues  of  the  mouth.  The 
hawksbill  forceps  (Standard  forceps  No.  8  and  No.  9)  come 
nearer  to  conforming  to  this  principle  than  any  other  forceps 
designed  for  the  inferior  anterior  teeth. 

Order  of  Extraction. — If  both  central  and  lateral  incisors  are 
to  be  removed,  and  conditions  pertaining  to  both  are  similar, 
the  extraction  of  the  centrals  should  precede  that  of  the  laterals. 
The  position  of  the  centrals  in  the  arch  affords  better  access. 
As  the  centrals  are  the  first  teeth  to  erupt,  they  are  less  fre- 
quently in  abnormal  position;  and,  as  they  are  smaller  and  have 
shorter  roots  than  the  laterals,  and  as  the  alveolar  process 
reaches  its  minimum  thickness  over  them,  they  are  correspond- 
ingly easier  to  extract. 

Application  of  Forceps. — More  difficulties  are  encountered  in 
the  application  of  the  forceps  to  the  teeth  in  the  inferior  arch 
than  in  their  application  to  the  superior  teeth.  The  parts  in  the 
inferior  arch  are  not  as  accessilile,  and  the  view  on  their  lingual 
sides  is  often  obstructed  by  the  tongue,  while  in  the  superior  arch 
there  is  an  open  field.  The  lower  jaw  being  mobile,  its  move- 
ments must  be  controlled,  and  the  teeth,  especially  if  badly 
broken  down,  are  often  immersed  in  saliva  and,  if  there  are  a 
number  of  extractions,  in  blood. 


INFERIOR  INCISORS  189 

One  beak  of  the  forceps  should  be  first  applied  to  the  lingual 
side  of  the  tooth,  passing  it  well  down  to  the  gum  margin,  fol- 
lowed by  the  application  of  the  opposing  beak  to  the  labial  side, 
and  this  order  of  applying  the  beaks  is  reversed  in  case  the  tooth 
is  badly  decayed  gingivally  on  its  labial  surface  and  the  lingual 
wall  is  comparatively  sound.  Holding  both  beaks  in  close  prox- 
imity to  the  tooth,  they  are  sent  down  rather  firmly,  but  never 
with  sufficient  force  to  break  down  the  process.  The  alveolar 
arch  that  rises  from  the  incisive  fossae  labially  and  from  the  de- 
pression above  the  genial  tubercles  lingually  is  much  narrower 
in  its  mesio-distal  diameter  at  its  base  than  at  its  margins.  This 
condition  and  the  narrowness  of  the  roots  of  these  teeth  should 
be  borne  in  mind,  and  care  taken  that  the  forceps  are  not  mis- 
directed, as  in  case  of  misdirection  of  the  forceps  the  beaks  would 
grasp  the  alveolar  process  surrounding  the  tooth  or  the  septum 
on  either  side  of  it,  thus  weakening  or  destroying  the  supporting 
tissues  of  an  adjacent  tooth,  thereby  unnecessarily  causing  its 
immediate  or  early  ]oss.  Any  rotated  position  of  a  tooth  should 
be  noted,  so  that  it  may  be  grasped  by  the  forceps  in  its  greatest 
transverse  diameter,  provided  the  adjoining  teeth  permit  such 
application. 

Alveolar  Application  of  Forceps. — Alveolar  application  of  the 
forceps  to  the  inferior  incisors  should  be  made  sparingly,  and, 
when  made,  should  be  done  with  caution.  This  application  is 
indicated  in  the  case  of  fracture  by  traumatism,  or  by  an 
attempted  extraction,  where  the  break  is  a  little  above  or  flush 
with  the  alveolar  margin;  in  case  of  decay  that  has  destroyed 
the  crown,  but  the  root  at  or  immediately  below  the  process  is 
firm;  and  in  some  cases  of  displacement.  Alveolar  application 
to  either  the  labial  or  lingual  side  may  also  be  made  indepen- 
dently of  the  opposing  side,  and  is  at  times  indicated. 

Application  is  made  by  passing  the  beaks  just  far  enough  over 
the  process  to  grasp  the  root,  and  never  below  the  marginal 
ridge.  The  danger  lies  in  letting  the  forceps  slip  all  the  way 
over  the  ridge  and  grasp  too  much  of  the  process,  and,  to  avoid 
this,  the  labial  beak  should  be  controlled  with  the  index  finger 
of  the  left  hand.  No  attempt  at  extraction  movements  should 
be  made  until  the  beaks  have  cut  through  the  process  and  en- 
gaged the  root,  which  part  of  the  procedure  is  readily  revealed 
by  a  cultivated  sense  of  touch,  and  the  pressure  applied  in  cut- 


190  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

ting  tlirougli  the  process  is  all  that  is  usually  necessary  to 
]oosen  the  root. 

Extraction  of  badly  decayed  or  deeply  seated  roots  of  inferior 
incisors  should  not  l)e  attempted  by  alveolar  application. 

Extraction  Movements. — Using  Standard  forceps  No.  6,  and 
having  applied  them  as  previously  described  (page  188)  and  as 
shown  in  Fig.  89,  A,  the  first  extraction  movement  is  made  by 
bringing  the  tooth  labially  (Fig.  89,  B),  followed  by  a  like  move- 
ment lingually  (Fig.  89,  C).  These  movements  are  repeated 
until  the  tooth  is  loosened  from  its  attachment,  when  it  is  carried 
from  its  socket  by  a  tractile  movement  upward  and  in  line  with 
its  original  position  (Fig.  89,  D).  The  same  technic  of  operation 
is  applicable  when  using  Standard  forceps  No.  8  or  No.  9.  The 
roots  of  the  inferior  incisors  are  smaller  and  more  fragile  than 
those  of  the  other  single-rooted  teeth,  and  the  force  of  the  extrac- 
tion movements  should  be  gauged  accordingly.  A  short  labio- 
lingual  movement  under  perfect  control  should  be  used  in  pref- 
erence to  any  extended  movement,  and  in  case  of  extensive  caries 
the  beaks  of  the  forceps  should  be  sent  as  firmly  against  the 
process  as  its  strength  will  bear  without  fracture. 

In  case  of  gingival  decay,  either  labially  or  lingually,  the  first 
extraction  movement  is  nmde  in  the  direction  of  the  cavity, 
followed  by  carrying  the  tooth  only  far  enough  in  the  opposite 
direction  to  take  up  the  space  gained  by  the  first  movement.  As 
the  roots  of  the  inferior  incisors  are  much  flattened  in  their  mesio- 
distal  diameter,  it  is  important  that  all  extraction  movements 
be  started  with  the  beaks  of  the  forceps  in  the  same  plane  as  the 
greatest  transverse  axis  of  the  tooth,  and  that  they  be  ke))t  in 
this  plane  throughout  all  the  movements.  The  compound  obtuse 
angle  by  which  the  power  is  transmitted  from  the  hand  to  these 
teeth — that  is,  when  using  any  forceps  other  than  the  hawksbill, 
some  of  whose  advantages  have  been  considered,  or  forceps 
canted  with  beaks  and  handles  at  right  angles,  and  which  can- 
not be  controlled  in  any  tractile  movement — demands  that  more 
than  ordinary  skill  and  judgment  be  exercised  in  the  extraction 
movements;  but  the  necessary  skill  and  judgment  should  be  ac- 
quired, as  a  high  percentage  of  failures  is  attributable  to  a  lack 
of  the  necessary  knowledge  of  the  tractile  movements.  The 
flattened  roots  preclude  any  attempt  at  rotatory  movements,  and 
even  in  the  presence  of  torsal  occlusion  all  lateral  force  should 


INFERIOR  INCISORS 


191 


B 


D 


Fig.  89.— Extraction  movements  for  inferior  incisor.  A.  forceps  (standard  No.  6)  ap- 
plied; B,  first  movement  to  the  labial  side;  C.  reversed  movement  to  the  Imgual 
side;  D,  tractile  movement  upward  in  line  with  the  original  position  of  the  tooth. 


192  EXTRACTION  TEGHNIC  OF  INFERIOR  TEETH 

be  exerted  in  the  direction  of  the  tooth's  greatest  transverse 
diameter,  provided  the  approximating  teeth  permit  such  pro- 
cedure. 

Displacement — Complete  Lingual.— hi  the  extraction  of  an 
inferior  incisor  that  is  in  complete  lingual  occlusion,  application 
should  be  made,  if  possible,  to  the  labial  and  lingual  surfaces 
with  either  Standard  forceps  No.  6,-  No.  8,  or  No.  9,  selecting  the 
pair  with  which  the  best  access  can  be  obtained.  There  will  be, 
however,  only  few  cases  in  which  labio-lingual  application  can 
be  made,  and,  if  impossible  to  make  it,  a  mesio-distal  one  is 
made,  using  Standard  forceps  No.  8  or  No.  9.  Application  hav- 
ing been  made,  the  tooth  is  forced  lingual ly,  using  the  minimum 
amount  of  force  necessary  to  break  up  its  attachment,  and 
attempting  only  sufficient  counter-movement  to  take  up  the 
space  thus  gained.  More  tractile  force  is  permissible  than  where 
the  same  tooth  is  in  normal  alignment,  but  such  force  must  be 
under  perfect  control,  so  as  to  avoid  the  possibility  of  injuring 
any  of  the  superior  teeth  wdtli  the  forceps  on  a  sudden  release 
of  the  tooth. 

Complete  Labial. — The  application  of  the  forceps  and  the  ex- 
traction movements  necessary  to  remove  an  inferior  incisor  in 
complete  labial  occlusion  is  identical  with  that  for  removing  the 
same  tooth  in  complete  lingual  occlusion,  except  that  the  order 
of  the  extraction  movements  is  reversed.  The  removal  of  the 
tooth  is  usually  less  difficult  than  when  in  lingual  occlusion,  as 
access  is  better,  and,  being  on  the  convex  instead  of  the  concave 
side  of  the  arch,  with  a  thinner  plate  of  process  for  its  support, 
the  attachment  is  not  so  firm.  The  greater  danger  lies  in  car- 
rying a  tooth  labially  with  more  force  than  is  necessary  to  loosen 
it  and  splitting  oft:  a  considerable  area  of  the  process. 

Partial. — Standard  forceps  No.  8  or  No.  9  are  especially  suited 
for  the  extraction  of  an  inferior  incisor  in  irregular  alignment, 
preference  being  given  to  those  with  the  broader  beaks,  provided 
one  of  the  beaks  can  be  introduced  between  the  crowded  teeth. 
Having  selected  the  forceps,  one  beak  is  first  applied  to  the 
labial  wall  in  lingual  displacement  and  to  the  lingual  wall  in 
labial  displacement,  passing  it  well  down  under  the  free  margin 
of  the  gum,  and  noting  the  relation  of  the  tooth  to  the  approxi- 
mating teeth,  so  that  the  latter  may  not  be  injured  by  the  extrac- 
tion movements  which  are  to  follow.     The  forceps  having  been 


INFERIOR  INCISORS  193 

ad  justed,  and  wliile  ]ioldiiii>'  the  tooth  only  firmly  enough  to 
prevent  it  slipping  from  adjustment,  the  lahio-lingual  or  the 
linguo-labial  movement,  depending  on  the  direction  of  misplace- 
ment, is  used  in  a  modiiled  form,  during  which  procedure  the 
forceps  are  sent  down  against  the  process  with  some  degree  of 
force,  but  never  sufficient  to  fracture  either  of  the  plates.  This 
downward  pressure  is  a  reliable  force  in  loosening  the  tooth 
from  its  attachment,  and  does  not  subject  the  adjoining  teeth  to 
the  dangers  of  the  broad  swaying  movement. 

The  practice  of  too  frequently  extracting  an  inferior  incisor 
to  relieve  a  crowded  condition  is  not  approved,  as  the  resultant 
loss  leaves  a  space  that  subjects  the  sui)porting  tissues  to  prob- 
ably grave  pathologic  conditions. 

Impaction. — An  inferior  incisor  is  seldom  impacted,  and,  when 
impacted,  it  is  usually  located  on  the  lingual  side  of  the  arch. 
To  extract  a  tooth  so  impacted,  an  incision  of  the  soft  tissue 
should  be  made  to  expose  the  crown  and  that  part  of  the  alveolus 
that  must  be  removed.  The  alveolus  is  then  dissected  away  from 
the  mesial  or  distal  side  of  the  tooth  to  a  distance  where  the 
l^oint  of  the  elevator  can  penetrate  the  root.  The  regular  or 
moditied  Cryer  elevator  (Figs.  24,  25)  is  selected,  and  the  blade 
adjusted  to  the  side  of  the  root,  sufficient  pressure  upward  being- 
applied  to  loosen  the  tooth  from  its  attachment,  and,  when  neces- 
sary, using  the  forceps  to  complete  the  operation. 

The  success  of  the  operation  is  dependent  on  removing  a  suffi- 
cient amount  of  osseous  tissue,  and  at  the  proper  place,  to  release 
the  tooth  from  its  imi)action,  and  therefore  the  operation  should 
not  be  attempted  without  a  correct  diagnosis  having  been  pre- 
viously made  with  a  radiograph. 

Fracture. — Unless  adequate  skill  has  been  acquired — including 
good  judgment  in  selecting  the  proper  method  of  operating  and 
the  exercise  of  due  precaution  in  executing  the  details  of  the 
operation — fracture  will  not  be  uncommon  in  the  attempted 
extraction  of  inferior  incisors,  especially  in  the  case  of  a  person 
past  the  meridian  of  life,  with  the  process  heavy  and  in  a  good 
state  of  i^reservation,  and  the  teeth  frail  and  in  a  poor  state  of 
preservation. 

In  case  of  fracture  anywhere  from  a  little  al)ove  to  a  short 
distance  below  the  process,  alveolar  application  should  be  made 
and  the  root  removed  as  if  no  fracture  had  occurred.     In  such 


194  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

case  and  also  in  deeper-seated  fracture,  if  tlie  two  approximating 
teeth  have  been  removed  at  the  same  sitting,  application  is  made 
by  introducing  the  beaks  of  Standard  forceps  No.  8  or  No.  9  into 
the  vacant  sockets,  and  cutting  through  the  septi  to  secure  an 
adjustment  on  the  root,  after  which  it  can  be  readily  removed. 
It  is  sometimes  necessary  to  remove  a  small  area  of  the  process 
with  a  bur  and  engage  the  part  thus  exposed  with  a  Cryer  ele- 
vator to  break  up  its  attachment.  It  is  not  infrequent  for  a 
tooth  to  fracture  obliquely,  and  the  latter  method  is  usually  very 
practicable  in  such  cases,  as,  by  selecting  the  most  elevated  part 
of  the  root,  application  can  be  made  with  the  Cryer  elevator  with 
little  or  no  loss  of  tissue. 

Roots. — In  the  extraction  of  the  root  of  an  inferior  incisor  the 
operator  is  governed  by  the  extent  of  decay  and  the  condition 
of  the  surrounding  structures.  For  most  cases  Standard  forceps 
No.  8  or  No.  9  are  used  in  preference  to  Standard  forceps  No.  6. 
If  sufficient  structure  remains  above  the  process  for  an  applica- 
tion, it  is  made  in  the  usual  way,  followed  by  a  firm  downward 
pressure  as  the  primary  extraction  movement,  and  combining 
this  movement  with  the  lateral  movements,  which  are  secondary. 
Just  enough  tension  is  placed  on  the  forceps  to  hold  them  in 
position  on  the  root,  as  any  greater  amount  increases  the  liability 
to  fracture  without  in  any  way  assisting  in  loosening  the  root. 

For  the  removal  of  a  root  that  possesses  considerable  strength 
at  or  immediately  below  the  marginal  ridge,  alveolar  application 
is  made  and  the  root  removed  in  the  same  manner  as  if  operat- 
ing on  a  tooth  free  of  caries.  Occasionally  a  case  is  presented 
with  one  wall  comparatively  sound  and  the  others  destroyed. 
If  the  sound  structure  is  mesial  or  distal,  good  work  can  be  done 
with  the  Cryer  elevator  (Fig.  24),  engaging  the  solid  portion  of 
the  root  with  the  point  of  the  instrument,  and  using  the  adjoin- 
ing septum  and  tooth  as  the  fulcrum.  If  the  sound  structure  is 
labial  or  lingual,  the  curved-shank  elevator  (Fig.  16)  is  some- 
times employed  for  the  extraction,  and  is  used  by  engaging  the 
part  intact  on  its  external  surface  as  close  as  possible  to  the 
process  and  carrying  it  in  the  opposite  direction. 

A  root  that  is  too  extensively  destroyed  to  be  removed  by  any 
of  the  above  methods  is  treated  as  a  deep-seated  root,  and  is 
extracted  by  the  technic  applicable  to  the  removal  of  such  root 
(page  195). 


INFERIOR  INCISORS  195 

For  operating  on  a  root  covered  with  liypertropliied  tissue, 
the  forceps  are  applied,  where  possible,  as  described  and  illus- 
trated for  superior  central  incisor  (page  116),  and  in  other  cases 
where  this  cannot  be  done  the  methods  described  for  deep-seated 
roots  may  be  used. 

As  the  roots  of  the  inferior  incisors  are  comparatively  small 
and  the  septi  separating  them  are  quite  large,  it  is  sometimes 
difficult  to  distinguish  septum  from  root,  and,  when  the  operator 
is  in  doubt,  the  parts  should  be  exposed  in  order  to  avoid  possible 
serious  damage  to  adjacent  teeth. 

Deep-Seated  Roots. — If  no  pathologic  condition  is  present,  it 
is  often  advisable  to  allow  small  tips  and  deep-seated  roots  of 
inferior  incisors  to  remain,  as  is  done  in  the  case  of  some  other 
teeth,  until  by  resorption  of  the  process  they  are  brought  nearer 
the  surface,  thereby  simplifying  what  would  otherwise  be  a 
tedious  operation. 

If  removal  is  necessary,  and  the  gum  tissue  interferes  with 
the  examination  or  operation,  which  it  usually  does,  it  may  be 
displaced  with  the  Derenberg  tweezers,  or  the  retractor  (Fig.  40) 
is  used  to  sjDread  the  tissue  and  expose  the  field  of  operation. 

If  the  process  is  weakened  and  the  root  is  not  firmly  attached, 
extraction  may  be  accomplished  by  carefully  passing  the  beaks 
of  Standard  forceps  No.  9  (Fig.  10)  between  the  dilated  gum  and 
over  the  process,  when  a  small  amount  of  pressure  will  force  the 
tooth  out  of  its  socket  with  very  little  injury  to  the  tissues.  A 
root  that  is  too  deeply  seated  for  this  operation  can  often  be 
removed  by  carefully  engaging  its  strongest  wall  with  the  Cryer 
elevator.  If,  however,  neither  of  these  methods  is  deemed  ad- 
visable, an  enamel  chisel  is  a  very  practical  instrument  to  use. 
Selecting  a  suitable  chisel  for  the  particular  case  presented,  it 
should  be  forced  down  between  the  root  and  process  on  the 
mesial  or  distal  side,  or  on  both,  and  a  combined  rotatory  and 
lever  action  is  applied  until  the  root  is  loosened,  when  removal 
is  completed  with  the  Derenberg  tweezers. 

Screw-Porte. — The  use  of  the  screw-porte  on  inferior  incisors 
is  limited,  and  should  not  be  depended  on  as  an  instrument  for 
their  extraction.  It  may,  however,  be  employed  in  a  few  cases 
of  deep-seated  roots  where  the  canal  is  sufficiently  enlarged  to 
receive  it,  and  in  some  cases  of  fracture  where  an  adjustment 
can  be  secured. 


196  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

Elevator. — The  use  of  the  elevator  for  the  extraction  of  inferior 
incisors  is  limited,  and  is  confined  to  the  Cryer,  with  an  occa- 
sional nse  of  the  cnrved-shank.  The  nse  of  the  elevator  in  im- 
pacted and  fracture  cases,  and  on  roots  deeply  seated,  exten- 
sively decayed,  or  covered  by  soft  tissue,  is  not  frequent,  and  its 
use  in  these  cases  is  therefore  described  under  the  respective 
headings. 

INFERIOR  CUSPID. 

The  inferior  cus])i(ls  ni'e  usually  the  hist  teeth  to  be  removed 
from  the  mouth — not  because  they  are  less  subject  to  decay  than 
the  inferior  incisors,  but  on  account  of  their  value  for  sup])ort- 
ing  various  kinds  of  artificial  work,  and  therefore  the  operator 
should  hesitate  to  remove  them  unless  their  extraction  is  abso- 
lutely necessary.  Fig.  !)()  shows  the  various  tyi)es  of  inferior 
cusi)ids  that  are  usunlly  seen,  and  attention  is  directed  to  the 
occasional  bifurcation  of  the  root  and  to  the  curvature  of  the 
root  at  its  apical  third. 

Position  of  Patient  and  Operator. — The  position  of  the  patient 
in  the  chair  and  that  of  the  operator  is  as  described  for  extract- 
ing inferior  teeth  (page  !)()).  The  position  of  the  arm  of  the 
operator  and  the  arrangement  of  the  liand  and  fingers  are  the 
same  as  described  for  the  inferior  incisors  (page  184),  but  the 
head  of  the  patient  is  turned  slightly  to  the  right  or  left,  as  the 
case  may  require. 

Figs.  91  and  92  show  the  forceps  applied  respectively  to  the 
right  and  left  side  of  the  arch.  These  two  positions  are  of  such 
importance  in  connection  with  these  teeth,  as  they  give  direct 
access  in  line  with  their  axes  and  allow  the  extraction  move- 
ments to  be  properly  executed,  that  they  are  both  illustrated, 
although  the  positions  are  similar  to  the  positions  for  the  in- 
ferior incisors  (page  184).  Fig.  93  shows  Standard  forceps  No.  8 
(Fig.  9)  applied  to  an  inferior  right  cuspid,  and  the  direct 
access  to  this  tooth  obtained  when  ai)plying  these  forceps  in  this 
manner. 

Forceps. — Standard  forceps  No.  6  (Fig.  7)  are  as  api)licable 
for  the  removal  of  the  inferior  cuspids  as  they  are  for  the  inferior 
incisors.  Standard  forceps  No.  8  (Fig.  9)  are  also  serviceable 
for  the  removal  of  the  inferior  cuspids,  and  are  frequently  em- 
ployed in  fracture  cases  and  where  decay  is  extensive,  especially 


INFERIOR  CUSPID 


197 


90. — Tyjies  of  inferior  cuspids, 
lingual,   the  third  row   the  n 


The  first  row  shows  the  labial,  the  second  row  the 
-sial,  and  the  fourth  row  the  distal  surface. 


198 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


for  the  inferior  right  cuspid.     In  impaction  and  crowded  condi- 
tions Standard  forceps  No.  9  (Fig.  10)  are  sometimes  used. 

Order  of  Extraction.— The  same  order  of  extraction  applies  to 
the  inferior  cuspid  as  to  the  superior  cuspid  (page  130).    Where 


Fig.  91. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  an  inferior  cuspid  on  the  right  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.  6)   to  the  inferior  right  cuspid. 

a  tooth  on  either  side  of  it  is  to  be  removed,  such  tooth  is  ex- 
tracted in  advance,  as  that  procedure  will  allow  a  better  adjust- 
ment of  the  forceps,  lessen  the  resistance  to  be  overcome  in  the 
removal  of  the  cuspid,  and  permit  the  extraction  movements  to 
be  more  effectively  made. 


INFERIOR  CUSPID 


199 


Application  of  Forceps.— The  application  of  the  forceps  to  a 
cuspid  is  the  same  as  that  described  for  an  incisor,  one  of  the 
beaks  being  first  applied  to  the  lingnal  surface,  followed  by  ap- 
plying the  opposing  beak  to  the  labial  surface,  using  the  same 


Pis  92  —Position  of  the  operator's  hands  and  disposition  of  the  Angers  when  applying 
torceps  to  an  inferior  cuspid  on  the  left  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.  6)  to  the  inferior  left  cuspid. 

precaution  to  avoid  engaging  the  soft  tissue  with  the  forceps  as 
is  exercised  with  the  incisors.  With  the  beaks  applied  as^  de- 
scribed, and  with  the  hand  well  back  over  the  end  of  the  right 
handle,  the  beaks  are  sent  down  with  sufficient  force  to  carry 
them  firmly  against  the  process. 


200  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

The  application  of  the  forceps  to  this  tooth,  when  properly 
made,  is  often  the  final  stage  of  the  operation,  as  frequently, 
when  the  beaks  are  applied  with  some  pressure  in  line  with  the 
axis  of  the  tooth,  if  the  root  is  of  a  conical  shape,  the  tooth  will 
be  loosened  by  the  application. 

Alveolar  Application  of  Forceps. — Where  the  alveolar  process 
surrounding  this  tooth  is  normal,  an  alveolar  application  is  not 
practicable,  and  especially  is  it  not  practicable  to  the  lingual 
surface.  The  tooth  l)eing  situated  at  the  angle  of  the  arch,  the 
alveolar  structure  on  the  inner  curvature  is  too  dense  to  allow  the 
beaks  to  cut  through  it  with  any  degree  of  success.  The  alveolar 
application  is  made  only  when  the  margins  of  the  alveolus  are 
carious,  and  this  affected  structure  should  bo  removed  at  the  time 
the  tooth  is  extracted. 

Extraction  Movements. — If  the  pressure  effected  in  the  api)li- 
cation  of  the  forceps  has  not  loosened  the  tooth,  the  extraction 
movements  described  and  illustrated  for  the  superior  cuspid 
(]^age  133)  are  used,  modifying  the  force  of  the  movements  to 
corres]iond  with  the  resistance  to  be  overcome. 

Displacement — Complete  Lahial. — CompU'te  la1)ial  displace- 
ment is  common  with  this  tooth,  and  the  method  of  extraction  is 
very  much  like  that  for  a  superior  cuspid  in  similar  displace- 
ment. The  mesial  and  distal  ai)])lication  should  be  made,  using 
Standard  forcei)s  No.  8  (Fig.  9)  if  space  permits;  and  if  the  dis- 
placed tooth  is  in  too  close  i)roximity  to  the  lateral  and  first 
bicuspid.  Standard  forceps  No.  9  (Fig.  10)  should  be  the  second 
choice.  The  first  and  principal  extraction  movement  is,  of  neces- 
sity, labially,  taking  up  such  space  as  is  gained  by  a  higher  appli- 
cation on  the  tooth.  If  resistance  is  unusually  strong,  it  may  be 
necessary  to  make  a  labio-lingual  application,  after  the  tooth  has 
been  forced  away  from  the  approximating  teeth,  before  complet- 
ing the  operation. 

If  the  crown  is  so  displaced  that  the  forceps  cannot  be  securely 
adjusted,  the  Cryer  elevator  (Fig.  24)  is  applied  to  the  distal  sur- 
face, sending  the  blade  down  to  where  the  point  of  the  instrument 
will  ]ienetrate  the  root  of  the  tooth.  This  application  having 
been  made,  the  first  bicus])id,  or,  if  its  use  is  not  feasible,  the 
alveolar  process,  is  used  as  a  fulcrum,  and  tlie  handle  of  the  ele- 
vator is  turned  distally  and  slightly  raised.  If  this  does  not 
loosen  the  tooth,  the  blade  is  released  from  the  point  of  ])enetra- 


INFERIOR  CUSPID 


201 


tioii  and  sent  further  down  on  the  root,  repeating  the  movement 
until  the  tooth  is  loosened  sufficiently  to  l)e  delivered  from  its 
socket  with  the  elevator  or  l)y  an  aijplication  of  the  forceps. 
Complete    Lingual. — This  tooth  is  not  often  completely  dis- 


Fig.  93.— Position  of  the  operator's  hands  and  disposition  of  the  Angers  when  appljing 
forceps  to  an  inferior  cuspid  on  the  right  side  of  the  arch.  Illustration  shows  the 
application  of  forceps   (Standard  No.   8)  to  the  inferior  right  cuspid. 

placed  to  the  lingual  side  of  the  arch,  but,  when  such  a  case  is 
presented,  the  use  of  the  (Vyer  elevator  should,  wherever  possi- 
ble, precede  the  forcejis.  The  elevator  should  be  applied  to  the 
distal  surface  of  the  tooth,  using  the  first  bicuspid  as  a  fulcrum. 
When  the  tooth  has  been  loosened,  either  Standard  forceps  No.  8 


/202  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

f 

or  No.  9  are  employed  to  complete  the  extraction.  Occasionally 
the  position  of  the  tooth  is  such  that  the  Cryer  elevator  cannot 
be  applied  far  enough  down  on  the  neck  of  the  cuspid  to  utilize 
the  first  bicuspid  as  the  fulcrum  without  endangering  the  loss 
of  the  latter  tooth,  and  this  difficulty  is  overcome  by  removing 
the  crown  of  the  cuspid  before  attempting  to  apply  the  elevator. 
It  is  needless  to  say  that  this  operation  should  not  be  under- 
taken except  under  a  general  anesthetic. 

A  simpler  operation,  and  one  that  is  recommended  wherever 
the  tooth  to  be  removed  is  in  a  fair  state  of  preservation,  and 
the  approximal  space  between  the  lateral  and  first  bicuspid  will 
permit  its  use,  is  to  loosen  the  tooth  with  a  mastoid  chisel.  This 
operation  is  performed  by  placing  the  chisel  against  the  laJbial 
side  of  the  tooth  at  its  neck,  and,  while  holding  the  chisel  at  an 
angle  of  about  forty-five  degrees,  striking  it  a  sharp  blow  with  a 
plugging  mallet.  The  amount  of  force  that  the  tooth  will  bear 
should  be  gauged,  and  it  will  be  better  to  apply  a  series  of  blows 
of  medium  force  than  to  possibly  fracture  the  tooth  by  too  great 
a  force  in  the  initial  blow. 

The  above  technic  is  equally  applicable  to  an  inferior  incisor 
when  in  similar  displacement,  modifying  the  operation  as  may 
be  necessary  for  the  particular  tooth  to  be  removed. 

Partial.— In  partial  displacement  of  this  tooth,  Standard  for- 
ceps No.  8  or  No.  9  are  used,  depending  on  the  amount  of  avail- 
able space  for  their  adjustment.  One  beak  is  first  applied  to  the 
labial  side  in  lingual  displacement  and  to  the  lingual  side  in 
labial  displacement,  followed  by  the  application  of  the  other  beak 
to  the  opposite  side,  and  when  adjusted  they  are  sent  against  the 
process  with  such  force  as  it  will  bear,  which  movement  will 
usually  loosen  the  tooth.  If  this  application  fails  to  loosen  the 
tooth,  the  next  force  is  applied  labially  in  labial  displacement 
and  lingually  in  lingual  displacement,  taking  up  such  space  as 
may  be  gained  by  a  reverse  movement,  and  repeating  these  alter- 
nating movements  until  the  tooth  is  released. 

Extensive  Caries  and  Roots. — If  the  destruction  of  the  tooth 
by  caries  is  principally  on  its  mesial  side,  with  comparatively 
good  structure  remaining  distally,  its  attachment  is  broken  up 
by  applying  the  Cryer  elevator  to  the  distal  side,  using  the  first 
bicuspid  as  the  fulcrum.  This  method  of  operation  cannot, 
however,  be  reversed  if  the  decay  is  on  the  distal  side,  as  the 


V 


^  INFERIOR  CUSPID  203 

lateral  incisor  does  not  possess  sufficient  strength  to  be  used  as 
a  fulcrum.  In  such  case  it  may  be  nedessary  to  remove  enough 
of  the  process  to  permit  a  dependable  application  of  Standard 
forceps  No.  8. 

If  the  seat  of  caries  is  located  labially  or  lingually,  but  not 
extensive  enough  to  materially  weaken  the  tooth,  the  forceps 
should  be  applied  as  though  the  loss  of  structure  did  not  exist, 
care  being  taken  that  the  beak  engaging  the  tooth  over  the  area 
of  decay  passes  below  the  gingival  margin  of  the  cavity.  The 
cavity  may  extend  below  the  process,  but  in  that  case  the  process 
is  usually  carious,  allowing  enough  alveolar  application  to  en- 
gage firm  tooth  structure.  If  the  lateral  and  first  bicuspids  have 
been  extracted,  mesial  and  distal  application  is  made.  The  first 
and  principal  extraction  movement  is  to  the  side  affected  by 
caries. 

The  method  for  removing  the  root  of  an  inferior  cuspid,  if 
sufficient  structure  remains  to  permit  the  use  of  the  forceps, 
differs  little  from  that  for  removing  the  superior  cuspid;  but  if 
decay  has  progressed  to  a  point  to  preclude  the  use  of  the  for- 
ceps, the  application  of  the  Cryer  elevator  is  usually  indicated, 
and  the  instrument  is  applied  to  the  distal  side  of  the  root. 

The  method  of  applying  the  forceps  to  an  inferior  cuspid  cov- 
ered by  gum  tissue  is  the  same  as  for  a  superior  central  incisor 
in  a  similar  condition  (page  116),  and,  as  the  process  surround- 
ing a.  root  in  this  condition  is  usually  carious,  especially  in 
the  inferior  arch,  the  pressure  of  application  usually  suffices  to 
extract  the  root. 

Seldom,  if  ever,  should  an  attempt  be  made  to  extract  an 
inferior  cuspid  root  with  the  forceps  if  the  root  is  deeply  seated. 
If  the  part  remaining  is  badly  reduced  by  caries,  it  is  removed 
with  the  Cryer  elevator;  but,  if  it  is  in  a  fair  state  of  preserva- 
tion, the  use  of  the  screw-porte  is  indicated,  as  the  position  of 
the  inferior  cuspid  and  the  shape  of  its  root  favor  the  use  of  this 
instrument. 

Impaction. — The  inferior  cuspid  is  seldom  impacted.  The 
technic  of  diagnosis  and  operation  in  impaction  are  the  same  as 
described  for  a  superior  cuspid  in  a  similar  condition  (page  137). 

Fracture. — Where  a  fracture  of  this  tooth  occurs  while  at- 
tempting to  extract  it  with  any  of  the  forceps  indicated  for  its 
extraction,  the  forceps  should  be  immediately  reapplied  if  the 


204  EXTRACTION  TEOHNIC  OF  INFERIOR  TEETH 

process  permits,  and  the  extraction  be  completed  as  tliougli  oper- 
ating on  a  root. 

Where  the  alveolus  is  projecting  above  the  root,  and  the  latter 
is  in  normal  condition,  it  is  often  practicable  to  engage  the  root 
with  the  screw-porte.  If,  however,  this  instrument  cannot  be 
used,  the  process  is  removed  from  the  distal  side  of  the  root  to 
allow  the  blade  of  the  Cryer  elevator  to  be  adjusted.  When  the 
elevator  is  applied,  sufficient  pressure  should  be  exerted  to  force 
the  root  from  its  socket,  and,  if  this  procedure  fails  to  release  the 
root,  alternately  turning  the  handle  of  the  elevator  distally  and 
repeating  the  pressure  will  deliver  the  root  from  its  socket. 

Where  the  fractured  i)art  is  deeply  seated,  and  consequently 
none  of  the  above  methods  can  be  applied,  the  remaining  part, 
if  it  is  not  liable  to  subsequently  give  any  trouble,  is  left  in  situ; 
but,  if  its  removal  is  deemed  necessary  on  account  of  existing 
conditions,  it  should  be  lemoved  with  a  bur  in  the  manner  de- 
scribed for  inferior  bicuspid  (])age  219). 

INFERIOR  FIRST  AND  SECOND  BICUSPIDS. 

The  technic  of  extraction  of  the  inferior  first  and  second 
bicuspids  is  so  nearly  the  same  in  all  its  details  that  the  two 
teeth  are  considered  together.  Fig.  94  shows  the  various  types 
of  inferior  bicus]iids  that  are  usually  seen. 

Position  of  Patient  and  Operator. — The  position  of  the  patient 
in  the  chair  and  that  of  the  operator  is  as  described  for  extracting 
inferior  teeth  (i)age  96).  The  placing  of  the  arm  of  the  opera- 
tor and  the  arrangement  of  the  hand  and  fingers  are  almost  the 
same  as  described  for  the  inferior  cuspid  (page  196).  The  head 
of  the  patient,  as  in  the  case  of  the  cuspid,  is  turned  to  the  right 
or  left,  as  the  case  may  require. 

AVhen  operating  on  the  left  side  of  the  arch  (Fig.  95),  the 
index  finger  is  placed  at  the  corner  of  the  mouth,  retracting  the 
lip;  the  second  finger  depresses  the  lower  lip,  exposing  the  field 
of  operation;  the  third  and  fourth  fingers  are  placed  below  the 
jaw. 

When  operating  on  the  right  side  of  the  arch  (Fig.  96),  the 
index  finger  is  placed  to  the  lingual  side  of  the  arch,  the  second 
finger  depresses  the  lower  lip,  and  the  third  and  fourth  fingers 
are  placed  below  the  lower  jaw.  Special  precaution  should  be 
taken,  when  operating  on  the  right  side  of  the  arch,  to  hold  the 


INFERIOR  FIRST  AND  SECOND  BICUSPIDS 


205 


Fig-  94.— Types  of  inferior  first  and  second  bicuspids.  First  row— first  five  teeth.  biK_ 
surface  of  first  bicuspids;  second  five  teeth,  buccal  surface  of  second  bicuspids. 
Second  row— first  five  teeth,  lingual  surface  of  first  bicuspids;  second  five  teeth 
lingual  surface  of  second  bicuspids.  Third  row— first  five  teeth,  mesial  surface  of 
first  bicuspids;  second  five  teeth,  mesial  surface  of  second  bicuspids.  Fourth  row 
—first  five  teeth,  distal  surface  of  first  bicuspids;  second  five  teeth,  distal  surface 
of  second  bicuspids. 


206 


EXTRACTION  TEGHNIC  OF  INFERIOR  TEETH 


lips  clear  of  the  field  of  operation,  as  otherwise  they  may  be 
caught  between  the  joints  of  the  forceps,  or,  in  case  of  misappli- 
cation of  the  forceps,  the  beaks  may  slip  from  their  adjustment 
and  bruise  these  tissues. 


Fig.  95. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  an  inferior  bicuspid  on  the  left  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.  6)  to  the  inferior  left  first  bicuspid. 

Forceps.— Standard  forceps  No.  6  (Fig.  7)  are  also  used  for 
the  extraction  of  the  inferior  first  and  second  bicuspids.  The 
beaks  of  these  forceps  should  be  kept  sharp  when  they  are  to  be 
employed  on  these  teeth,  as  dependence  is  frequently  placed  on 
them  to  cut  through  the  alveolus  in  cases  where  alveolar  applica- 


INFERIOR  FIRHT  AND  SECOND  BICUSPIDS 


•207 


tion  is  indicated.  As  the  edges  of  the  beaks  of  forceps  that  are 
used  quite  frequently  become  dull  or  will  turn,  and  as  the  necks 
of  these  teeth  are  often  narrowed,  the  beaks  should  always  be 
in  good  order. 


Fig.  96.— Position  of  the  operator's  hands  and  disposition  of  the  Angers  when  applying 
forceps  to  an  inferior  bicuspid  on  the  right  side  of  the  arch  Illustration  shows  the 
application  of  forceps   (Standard  No.  6)   to  the  inferior  right  second  bicuspid. 

Where  one  of  these  teeth  is  displaced  out  of  alignment  of  the 
arch,  either  Standard  forceps  No.  8  or  No.  9  (Figs.  9,  10)  should 
be  used;  and  where  the  tooth  is  completely  displaced  on  the 
lingual  side  of  the  arch.  Standard  forceps  No.  2  (Fig.  2)  may  be 
indicated. 


208  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

Order  of  Extraction. — AVliere  Iwtli  the  inferior  first  bicuspid 
and  enspid  are  to  be  removed,  the  removal  of  the  bienspid,  if  it 
is  the  simpler  operation,  should  i3recede  the  removal  of  the 
cusi3id.  Where  both  the  inferior  first  and  second  bicuspids  are 
to  be  removed,  the  removal  of  the  second  bicuspid,  if  conditions 
are  equal,  should  ])recede  the  removal  of  the  first  bicuspid. 

Application  of  Forceps. — In  the  application  of  the  forceps  to 
one  of  these  teeth,  when  properly  made,  as  in  the  case  of  the  in- 
ferior cuspid  (page  199),  one  of  the  beaks  is  first  applied  to  the 
lingual  surface,  followed  by  applying  the  opposing  beak  to  the 
buccal  surface,  when  pressure  downward  is  immediately  effected, 
sending  the  forceps  as  far  as  possible  down  on  the  neck  of  the 
tooth  without  injury  to  the  margin  of  the  alveolar  process. 

Where  the  cuspid  is  missing  from  the  arch,  or  its  crown  has 
been  attacked  by  caries,  leaving  only  the  root,  the  first  bicuspid 
is  frequently  found  inclining-  mesially.  In  this  case  the  applica- 
tion, if  Standard  forceps  No.  6  (Fig.  7)  are  employed,  should  be 
made  so  that  the  beaks  are  kept  in  line  with  the  axis  of  the  tooth, 
and  the  extraction  movements  should  be  made  in  the  same  plane. 
AVhere  direct  application  in  such  cases  cannot  be  obtained  with 
Standard  forceps  No.  6,  Standard  forceps  No.  2  (Fig.  2)  may  be 
used,  the  operator  assuming  a  position  in  front  of  the  patient 
when  applying  the  forceps  and  executing  the  extraction  move- 
ments. The  same  technic  applies  to  the  inferior  second  bicuspid 
when  in  similar  condition. 

Alveolar  Application  of  Forceps. — The  location  of  the  inferior 
bicuspids  and  the  process  surrounding  them  are  more  favorable 
for  an  alveolar  application  of  the  forceps  than  are  the  conditions 
of  any  of  the  other  teeth.  Excessive  alveolar  application  is  not 
advocated,  but,  when  cautiously  made,  this  form  of  application 
to  these  teeth  may  ))e  indicated  even  when  these  teeth  are  sup- 
ported by  a  normal,  healthy  process,  and  it  is  usually  indicated 
when  the  process  is  in  a  carious  condition.  It  is  made  prefer- 
ably with  Standard  forceps  No.  6,  but  occasionally  it  may  be- 
come necessary  to  use  Standard  forceps  No.  8  or  No.  9.  When 
making  an  alveolar  application,  the  operator  should  be  careful 
to  adjust  the  beaks  so  that  they  will  cut  through  the  alveolus 
covering  the  root  and  not  intrude  on  any  approximal  alveolus, 
and  no  extraction  movement  should  be  attempted  until  the  for- 
ceps have  severed  the  process  and  engaged  the  root. 


INFERIOR  FIRST  AND  SECOND  BICUSPIDS 


209 


SpF" 


D 


E 


F 


Fig.  97. — Extraction  movements  for  inferior  first  and  second  bicuspids.  A,  forceps 
(Standard  No.  6)  applied;  B,  first  movement  to  tlie  lingual  side;  C,  reversed  move- 
ment to  the  buccal  side;  D,  rotatory  movement  from  the  mesial  to  the  buccal  side; 
E,  reversed  rotatory  movement;  F,  tractile  movement  uyiward  in  line  with  tlie 
original  position  of  the  tooth. 


210  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

Extraction  Movements. — When  Standard  forceps  No.  6  have 
been  securely  adjusted,  as  shown  in  Fig.  97,  A,  which  shows 
them  applied  to  the  inferior  first  bicuspid,  and  if  the  pressure 
that  has  been  effected  when  making  the  application  has  not  loos- 
ened the  tooth,  the  first  extraction  movement  is  made  by  bring- 
ing the  tooth  with  a  slight  force  to  the  lingual  side  (Fig.  97,  B), 
followed  by  a  movement  with  about  the  same  force  to  the  buccal 
side  (Fig.  97,  C).  If  these  movements  do  not  loosen  the  tooth 
sufficiently  for  the  tractile  movement  to  be  made,  a  rotatory 
movement  is  executed  by  turning  the  mesial  surface  slightly 
buccally  (Fig.  97,  D).  If  it  is  observed  that  the  tooth  does  not 
yield  to  this  movement,  it  should  not  be  forced,  but,  if  it  does 
give  in  that  direction,  the  movement  should  be  followed  by  the 
reversed  rotatory  movement  (Fig.  97,  E).  When  the  tooth  is 
loosened  during  the  execution  of  any  of  these  movements,  it  is 
carried  from  its  socket  by  a  tractile  movement  upward  and  m 
line  with  its  original  position  (Fig.  97,  F).  If  resistance  to  the 
rotatory  movement  is  such  that  this  movement  cannot  be  exe- 
cuted without  subjecting  the  tooth  to  undue  stress,  the  operator 
may  surmise  that  the  root  is  flattened  on  its  mesial  and  distal 
surfaces,  and  in  that  case  the  lingual  and  buccal  movements 
should  be  more  forcibly  repeated  until  the  tooth  is  sufficiently 
detached  to  be  conveyed  from  the  socket  by  the  tractile  move- 
ment. Where  the  first  or  second  bicuspid  is  firmly  attached  to 
its  supporting  tissues- — as,  for  example,  in  the  case  of  one  that 
has  been  standing  alone  for  some  time,  with  the  process  very 
heavy  around  it — the  extraction  movements  should  be  slow  and 
cautious,  and  no  tractile  movement  should  be  attempted  until  the 
tooth  has  been  entirely  detached,  as  an  attempt  to  remove  the 
tooth  from  its  socket  by  this  movement  before  its  attachment  has 
been  broken  up  will  result  in  a  fracture. 

Displacement — fjoniplete  L'nif/ual. — It  is  not  unusual  to  find 
the  inferior  first  or  second  bicuspid  completely  displaced  to  the 
lingual  side  of  the  arch,  a  condition  that  makes  it  impracticable 
in  most  cases  to  satisfactorily  employ  Standard  forceps  No.  6, 
No.  8,  or  No.  9,  and  apply  the  necessary  extraction  movements 
for  its  removal. 

Where  one  of  these  teeth  is  so  displaced,  with  its  crown  directed 
toward  the  tongue  (Fig.  98),  the  operator  should  assume  a  posi- 
tion on  the  side  of  the  patient  opposite  to  that  on  which  the  tooth 


INFERIOR  FIRST  AND  SECOND  BICUSPIDS 


211 


is  located,  and  Standard  forceps  No.  2  are  selected  and  applied 
(Fig.  99).  Applying  the  forceps  in  this  manner  gives  a  more 
direct  access  to  the  tooth,  and  permits  a  wider  range  for  the 
extraction  movements,  which  are  necessarily  limited  by  the  ab- 
normal position  of  the  tooth.  When  the  forceps  are  securely 
adjusted,  a  right  or  left  rotatory  movement  of  the  tooth  is  made, 
and  the  particular  movement  that  has  been  made  is  reversed.  If 
these  two  movements  do  not  loosen  the  tooth,  a  slight  force  is 
exerted  lingually  and,  in  reversed  direction,  l)uccally,  which  is 


Fig.   98. — Inferior  right  .second  bicuspid  in 
complete  lingual   displacement. 


Fig.  99. — Same  subject  as  Fig.  98.  Stand- 
ard forceps  No.  2  applied  to  the  in- 
ferior right  second  bicuspid  in  com- 
plete lingual  displacement  from  posi- 
tion on  left  side  of  patient. 


followed  by  the  application  of  a  tractile  movement  as  near  as 
possible  in  line  with  the  original  position  of  the  tooth.  Apply- 
ing too  great  a  force  during  the  extraction  movements,  or  exert- 
ing too  much  pressure  on  the  beaks,  will  result  in  a  fracture  and 
complicate  the  case,  and  therefore  every  precaution  should  be 
taken  to  avoid  such  mistakes.  Rarely  is  a  case  presented  with 
the  conditions  mentioned  where  Standard  forceps  No.  2  (Fig.  2) 
cannot  be  engaged  as  described;  but,  if  such  a  case  occurs,  the 
operator  should  resort  to  the  use  of  the  modified  Cryer  elevator 
(Fig.  25),  applying  ilie  blade  to  the  mesial  surface  of  the  tooth 


212  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

and  engaging-  the  tooth  anterior  or  the  alveolar  process  as  a 
fulcrum.  When  the  elevator  is  firmly  adjusted,  the  handle  is 
turned  mesially  to  loosen  or  release  the  tooth.  Repeated  appli- 
cation of  the  blade  of  the  elevator  with  considerable  force  and 
the  accompanying  turning  of  the  handle  will  be  necessary  in 
some  cases  to  disengage  the  tooth.  The  elevator  is  also  used  in 
the  manner  described  where  the  crown  is  extensively  decayed  or 
has  fractured,  and  the  beaks  of  the  forceps  cannot  be  securely 
adjusted. 

Complete  Buccal. — Where  one  of  these  teeth  is  displaced  com- 
pletely out  of  alignment  to  the  buccal  side  of  the  arch,  and  the 
space  on  the  lingual  side  will  permit  either  Standard  forceps 
No.  8  or  No.  9  (hawksbill.  Figs.  9,  10)  to  be  used,  such  forceps 
should  be  selected.  One  beak  is  first  inserted  into  the  narrowed 
space  between  the  approximating  teeth  and  applied  to  the  lingual 
surface  of  the  tooth,  after  which  the  opposing  beak  is  applied  to 
the  buccal  surface.  When  both  beaks  are  j)laced,  pressure  is 
applied  downward,  and,  when  an  adjustment  has  been  secured, 
the  first  extraction  movement  is  made  to  the  buccal  side.  This 
movement  should,  however,  be  very  slight,  and  only  sufficient  to 
secure  a  reapplication  of  the  beaks  of  the  forceps,  so  that  the 
beak  which  is  engaged  in  the  narrow  space  can  be  sent  further 
down  on  the  lingual  surface.  When  the  additional  space  has 
been  obtained,  another  movement  more  forcibly  buccally  is  made, 
after  which  the  tooth  is  returned  as  near  as  possible  to  its  origi- 
nal position,  and  partially  rotated  if  at  all  practicable,  or  the 
buccal  movement  is  more  forcibly  repeated.  When  the  tooth  is 
loosened,  the  extraction  is  completed  by  a  tractile  movement  up- 
ward in  line  with  its  axis. 

Where  the  beak  cannot  be  applied  to  the  lingual  surface  of  the 
tooth,  space  can  often  be  gained  by  applying  the  Cryer  elevator 
(Fig.  24)  to  the  mesio-lingual  surface,  using  the  same  teclmic 
as  when  the  elevator  is  employed  for  this  tooth  displaced  to  the 
lingual  side  of  the  arch  (page  210). 

If,  on  account  of  the  lack  of  space,  it  is  impossible  to  apply  the 
hawksbill  forceps,  and  space  cannot  be  obtained  with  the  Cryer 
elevator,  an  application  should  l)e  made  to  the  mesial  and  distal 
surfaces  of  the  tooth  with  Standard  forceps  No.  6  (Fig.  7). 
After  taking  hold  of  the  crown  in  this  manner,  the  tooth  is 
brought  slightly  buccally.     When  this  has  been  done,  and  space 


IXFERIOR  FIRST  AXD   SECOND  BICUSPIDS  213 

obtained  on  the  lingual  side,  the  tooth  is  released,  and  the  hawks- 
bill  forcejDS  are  adjusted  to  the  lingual  and  buccal  surfaces,  being- 
sent  down  as  far  as  possible  on  the  tooth  without  injuring  the 
adjacent  teeth,  after  which  the  extraction  movements  are  made 
as  described  above. 

The  liability  of  the  tooth  to  fracture  in  these  cases  continually 
confronts  the  operator,  and  each  movement  should  be  under 
perfect  control  and  never  hastily  executed.  If  the  operator 
is  of  the  opinion  that  there  is  a  probability  of  the  tooth  fractur- 
ing, it  will  be  better  to  discontinue  the  use  of  the  forceps  or  ele- 
vator and  use  a  bur  to  dissect  away  part  of  the  alveolar  process 
on  the  buccal  side,  so  that  the  tooth  may  be  more  readily  released 
and  the  accident  of  fracture  avoided. 

Partial. — Where  one  of  these  teeth  is  partially  out  of  align- 
ment either  to  the  lingual  or  buccal  side  of  the  arch,  Standard 
forceps  No.  6  may  be  applied  if  they  can  be  adjusted.  If,  how- 
ever, these  forceps  cannot  be  used,  then  either  of  the  hawksbill 
forceps  are  selected.  As  in  the  case  where  the  tooth  is  com- 
pletely displaced  buccally,  one  beak  is  first  applied  to  the  surface 
of  the  tooth  within  the  narrowed  approximating  space,  followed 
by  applying  the  opposing  beak  to  the  other  side.  The  extraction 
movements  are  principally  toward  the  lingual  side  where  the 
tooth  is  displaced  in  that  direction,  and  are  reversed  when  the 
tooth  is  displaced  buccally,  employing  the  rotatory  movement 
when  practicable. 

Caries  on  Buccal  or  Lingual  Surface. — Where  caries  involves 
the  buccal  or  lingual  surface  of  these  teeth,  and  enough  of  the 
neck  of  the  tooth  remains  to  allow  a  firm  adjustment  of  Standard 
forceps  No.  6,  these  forceps  should  be  employed,  one  beak  being 
first  applied  to  the  side  attacked  by  caries  and  the  other  beak 
a])plied  to  the  opposite  side,  after  which  the  extraction  move- 
ments follow  as  descril)ed  for  this  tooth  where  the  crown  is  intact 
(page  210).  Where  the  cavity  extends  below  the  gum  margin, 
the  beak  on  the  involved  side  is  sent  quite  a  distance  downward, 
and  an  alveolai-  a])i)lication  may  be  made  to  insure  a  firm  grasp 
on  the  tooth.  A  f()rcil)le  moxcment  is  then  made  to  the  affected 
side,  which  is  followed  Ity  a  rotatory  movement  if  tlie  shape  of 
the  root  ]ioniiits  this  movement.  If  these  movements  fail  to  re- 
lease the  tooth,  a  cautious  movement  is  made  to  the  unaffected 
side,  which  is  followed  bv  hriniiinii'  the  tooth  with  increased  force 


214 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


to  the  involved  side;  and  if  by  these  efforts  the  tooth  is  not  re 
leased,  the  movements  shonld  be  repeated  with  increased  force 
nnti]  the  release  of  the  tooth  is  effected. 

Caries  on  Mesial  or  Distal  Surface. — Where  one  of  these  teeth 
is  attacked  by  caries  on  the  mesial  or  distal  surface,  and  enough 
of  the  neck  of  the  tooth  remains  to  allow  a  firm  adjustment  of 
Standard  forceps  No.  6  (Fig.  7),  these  forceps  should  be  em- 
]:>loyed,  and  the  extraction  movements  are  executed  as  described 
for  this  tooth  with  the  crown  intact  (page  210).  If,  however,  the 
greater  part  of  the  crown  is  destroyed  on  either  of  these  sides, 
and  caries  extends  below  the  neck  of  the  tooth,  which  contrain- 
dicates  the  use  of  the  force])s,  the  (*ryer  elevator  (Fig.  24)  should 
be  applied  to  that  side  of  the  tooth  which  has  not  l)een  weakened 
by  caries.     For  example,  when  the  cavity  is  on  the  distal  surface 


P'ig.  100. — Inferior  first  bicuspid  root 
weakened  by  caries  on  tlie  distal  sur- 
face. 


Fig.  101. — Same  subject  as  Fig.  100.  Cryer 
elevator  (Fig.  24)  applied  in  the  in- 
terproximal space  between  the  cuspid 
and  first  bicuspid  root. 


of  the  first  bicuspid  ( Fig.  100),  the  i)oiiit  of  the  Cryer  elevator  is 
applied  in  the  interi)roximal  space  on  the  mesial  side  (Fig.  101), 
and,  when  so  applied,  a  pressure  calculated  to  cause  the  blade  to 
penetrate  the  mesial  side  of  the  root  is  effected.  When  a  firm 
adjustment  has  been  obtained,  the  top  of  the  handle  of  the  eleva- 
tor is  turned  mesially,  using  the  cuspid  as  a  fulcrum.  In  most 
cases  this  movement  will  either  loosen  or  entirely  release  the 
tooth,  but,  if  greater  resistance  is  met  than  this  force  will  over- 
come, the  movement  should  be  repeated,  sending  the  blade 
further  down  on  the  root  with  each  movement,  thus  using  the 
elevator  as  a  wedge  and  also  increasing  the  amount  of  leverage. 
There  will  be  cases  where  the  tooth  cannot  be  entirelj^  liberated 
by  this  technic,  and  where  such  a  case  is  presented  the  tooth 
should  be  forced  out  of  the  socket  with  the  elevator  only  far 


INFERIOR  FIRST  AND  SECOND  BICUSPIDS  215 

enougli  to  allow  the  forceps  to  ])e  adjusted  to  complete  the  ex- 
traction. AVhen  operating-  on  the  second  hicnspid,  the  adjust- 
ment of  the  elevator  is  preferably  made  to  the  distal  surface,  as 
the  first  molar  makes  an  ideal  fulcrum.  Where  the  adjustment 
is  made  to  the  mesial  surface  of  the  first  or  second  bicuspid,  and 
the  tooth  posterior  to  the  one  to  be  extracted  is  missing,  extrac- 
tion of  the  tooth  is  much  simplified.  "Where  the  mesial  surface 
is  involved,  preventing  an  a|)plication  of  the  elevator  to  this 
surface,  and  the  tooth  posterior  to  it  is  missing,  the  alveolus  at 
the  distal  side  is  used  as  a  fulcrum. 

Roots. — Where  only  the  root  of  one  of  these  teeth  remains,  and 
the  buccal  and  lingual  sides  are  strong  enough  to  support  Stan- 
dard forceps  No.  6  (Fig.  7),  these  forceps  may  be  employed,  and 
the  extraction  movements  made  as  when  the  crown  is  intact 
(page  210). 

Where  Standard  forceps  No.  6  cannot  be  securely  adjusted, 
and  the  mesial  and  distal  sides  are  strong  enough  to  permit  the 
application  of  the  Cryer  elevator  (Fig.  24)  as  described  when 
caries  exists  on  the  mesial  or  distal  surface  (page  214),  this 
instrument  is  to  be  preferred  for  its  extraction.  Less  destruc- 
tion of  the  hard  and  soft  tissues  is  caused  by  this  method  than 
by  an  attempted  use  of  the  forceps,  and  in  the  majority  of 
instances  the  root  can  be  more  readily  extracted  by  this  method 
than  by  any  other. 

Where  the  sides  of  the  root  have  been  attacked  by  caries  to 
such  an  extent  that  neither  Standard  forceps  No.  6  nor  the  Cryer 
elevator  can  be  successfully  used,  either  Standard  forceps  No.  8 
or  No.  9  (hawksbill,  Figs.  9,  10)  should  be  employed,  and,  if 
necessary,  an  alveolar  application  is  made  to  secure  a  firm  ad- 
justment for  the  completion  of  the  extraction  movements. 

Where  the  root  is  not  firmly  attached,  and  also  where  only  the 
buccal  or  lingual  wall  remains,  the  curved-shank  elevator 
(Fig.  16)  may  be  used  as  described  on  page  30. 

Roots  Covered  by  Gum  Tissue. — Where  the  gum  tissue  covers 
the  root  of  one  of  these  teeth,  the  adjustment  of  the  forceps  is 
made  with  some  degree  of  guesswork,  and  may  cause  an  unnec- 
essary destruction  of  tissues,  with  uncertainty  as  to  the  final 
result.  The  author's  experience  has  been  that  a  surer,  quicker, 
and  better  operation  can  be  accomplished  with  the  elevator  than 
with  the  forceps  in  a  majority  of  these  cases.     The  technic  of 


216  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

operation  is  the  same  as  described  for  employing  the  elevator 
when  the  cavity  is  on  the  mesial  or  distal  surface  (page  214),  the 
elevator  being  applied  to  whichever  surface  of  the  root  that  an 
explorative  examination  indicates  as  having  the  strongest  wall. 
The  blade  of  the  elevator  presses  back  the  soft  tissue  from  over 
the  root  or  cuts  through  this  tissue  to  gain  the  adjustment. 

Roots  Wedged  Between  Adjacent  Teeth. — Where  the  crown 
of  a  tooth  has  been  destroyed  l)y  caries  to  such  an  extent  that 
only  the  root  is  left  w  sifx,  the  adjacent  teeth  will  often  be 
deflected  so  as  to  partially  close  the  space  formerly  occupied  by 
its  crown,  and  Fig.  102  shows  an  inferior  first  bicuspid  root  so 
situated.  In  such  case  the  operator  should  first  ascertain,  by 
careful  examination,  the  strength  of  the  marginal  edges  of  the 
root,  the  condition  of  the  alveolar  process  on  the  lingual  and 


Fig-.   102. — Root  of  an   inferior  first  liicu.spid  wedged  between   tlie  two  adjacent  teeth. 

buccal  sides,  and  how  far  it  may  l)e  possible  to  carry  the  root 
from  its  socket  without  interfering  with  the  adjacent  teeth.  If 
a  reasonably  strong  structure  remains  on  the  buccal  and  lingual 
surfaces,  the  operator  selects  either  Standard  forceps  No.  8  or 
No.  9  (Figs.  9,  10).  The  curvature  of  the  beaks  of  these  forceps 
favors  a  direct  application  without  interfering  with  the  adjacent 
teeth.  When  the  adjustment  has  been  made,  it  is  followed  by 
the  lingual  and  buccal  movements,  and  then  a  tractile  movement 
to  raise  the  root  slightly  out  of  the  socket.  If  the  tractile  move- 
ment cannot  be  executed,  a  more  forcil)le  movement  to  the  lin- 
gual aud  buccal  sides  is  re])eated  until  the  tooth  is  well  loosened 
from  its  attachment.  If  the  tooth  can  be  moved  buccally,  it  is 
sent  in  that  direction,  after  which  the  forceps  are  released  and 
applied  to  the  mesial  and  distal  surfaces,  and  the  extraction  is 


INFERIOR  FIRST  AND  SECOND  BICUSPIDS 


217 


completed  toward  the  buccal  side.  If,  however,  the  extraction 
cannot  be  completed  by  this  method  after  the  root  has  been 
loosened,  it  is  raised  far  enough  to  allow  the  straight-shank  ele- 
vator (Fig.  15)  to  be  applied  to  the  buccal  surface  of  the  root 
(Fig.  103),  when  pressure  is  directed  toward  the  lingual  side 
with  sufficient  force  to  release  the  root  in  that  direction.  If 
this  procedure  does  not  entirely  liberate  the  root,  it  can  usually 
be  pressed  lingually  far  enough  to  allow  the  extraction  to  be 
completed  from  a  position  of  the  operator  on  the  side  of  the  pa- 
tient opposite  to  the  location  of  the  tooth  by  applying  Standard 


Fig.  103.— Same  subject  as  Fig.  102.  Straight-shank  elevator  (Fig.  15)  applied  to  the 
buccal  surface  of  an  inferior  first  bicuspid  root,  wedged  between  the  adjacent 
teeth,  to  remove  it  after  it  has  been  loosened  with  forceps  or  elevator. 

forceps  No.  2,  and  employing  them  as  where  the  tooth  is  dis- 
placed on  the  lingual  side,  as  shown  in  Fig.  99. 

An  operator  who  is  accustomed  to  operating  with  hawksbili 
forceps  may  save  a  change  of  instruments  by  utilizing  one  of  its 
beaks  as  an  elevator,  applying  it  to  the  buccal  surface  of  the 
root  and  directing  the  pressure  lingually.  A  wedged  tooth 
should  never  be  raised  in  the  socket  further  than  the  free  ap- 
proximating space  will  ])crmit,  as  an  attempt  to  raise  it  further 
may  interfere  with  its  successful  extraction,  and  is  liable  to 
loosen  the  adjacent  teeth.  The  tooth  should,  however,  if  possi 
ble,  ])e  raised  in  the  socket  far  enough  to  allow  it  to  pass  in  a 
buccal  o]-  lingual  direction;  and,  if  lifted  beyond  this  point,  it 


218  EXTRACTION  TECHNIG  OF  INFERIOR  TEETH 

should  be  pressed  back  to  where  it  can  be  directed  toward  either 
of  these  sides. 

If  the  root  of  the  tooth  is  so  frail  as  not  to  permit  a  secure 
adjustment  of  the  beaks  of  the  forceps,  or  if  the  sides  that  are 
seized  by  the  beaks  fracture  during  the  attempted  removal,  the 
Cryer  elevator  should  ])e  used.  The  elevator  is  applied  to  the 
mesial  or  distal  side  of  the  root,  using  the  adjacent  tooth  as  a 
fulcrum.  The  root  is  loosened  from  its  attachment  with  the 
elevator,  but,  as  in  the  case  of  using  the  hawksbill  forceps,  the 
root  should  not  be  raised  to  where  it  will  come  in  contact  with 
the  crowns  of  the  deflected  teeth.  Tlie  straight-shank  elevator  is 
then  applied  to  the  buccal  side  of  the  root,  as  described  above, 
to  displace  the  root  lingually.  If  this  technic  cannot  be  exe- 
cuted, it  becomes  necessary  to  bur  away  the  alveolar  process 
from  the  buccal  or  lingual  plate  to  expose  the  root,  when  an 
elevator  is  applied  to  the  opposite  surface  and  the  root  is 
directed  from  the  socket  toward  the  side  where  the  process  has 
been  dissected  away  from  it. 

Screw-Porte. — The  screw-poi-te  may,  in  some  instances,  be 
used  advantageously  in  a  case  of  the  first  bicuspid  where  that 
tooth  has  been  fractured  (page  219),  especially  if  the  case  is 
complicated  with  hypercemeutosis.  This  instrument  is,  how- 
ever, seldom  used  for  the  second  bicuspid,  being  applied  only 
where  good  access  can  be  obtained. 

Impaction. — The  inferior  first  and  second  bicuspids  are  not 
very  often  impacted,  and,  when  this  condition  exists,  it  does  not 
cause  the  disturbance  that  is  usually  associated  with  the  superior 
or  inferior  third  molar.  The  tooth,  when  in  this  condition,  is 
as  a  rule  left  in  situ,,  and,  if  an  operation  is  considered  necessary, 
a  radiograph  should  be  first  obtained  in  order  to  establish  its 
exact  position.  If  the  tooth  is  located  on  the  lingual  side  of  the 
arch,  the  lingual  plate  of  the  alveolar  process  is  removed,  using 
the  technic  of  operation  described  for  removing  the  plate  when 
operating  on  the  inferior  third  molar  (page  311 ).  If  the  impac- 
tion is  on  the  buccal  side  of  the  arch,  the  buccal  plate  is  removed 
in  the  same  manner  as  described  for  the  removal  of  the  lingual 
plate.  After  the  plate  is  removed  the  tooth  is  released  from  its 
imbedded  position  by  applying  the  Cryer  elevator  at  the  most 
available  location  to  carry  the  tooth  in  the  direction  of  least 
resistance. 


INFERIOR  FIRST  AND  SECOND  BICUSPIDS  219 

Fracture. — Where  a  fracture  occurs  during  the  extraction 
movements  with  Standard  forceps  No.  6  (Fig.  7),  a  readjustment 
of  the  forceps  is  made  if  sufficient  structure  remains  for  that 
purpose,  as  is  done  when  such  an  accident  happens  with  the 
cuspid.  Where  the  neck  of  the  root  is  fragile  and  the  alveolus 
weakened,  either  Standard  forceps  No.  8  or  No.  9  (hawksbill, 
Figs.  9,  10)  may  be  used  and  an  alveohir  {ipplication  made. 
Where  the  operator  1ias  reason  to  suspect  tliat  a  firm  adjustment 
cannot  be  obtained  witli  the  forceps,  the  Cryer  elevator  (Fig.  24) 
is  applied  to  either  the  mesial  or  distal  surface,  employing  the 
technic  descril)ed  when  caries  involves  either  of  these  surfaces 
(page  214).  AVhere  the  remaining  root,  if  it  is  that  of  the  first 
bicuspid,  is  of  considerable  size,  with  a  large  root  canal  and  the 


3M«S^-^ 


;^ 


Fig.   104. — Method   of  using  a  bur  to  remove  a  small  part  of  a   root  of  an  inferior  first 
bicuspid  beyond  the  reach  of  forceps  or  elevator. 

alveolus  firm  and  projecting  beyond  the  root,  a  practicable 
method  is  to  use  the  screw-porte.  This  instrument  is  inserted 
into  the  root  canal,  and,  when  firmly  fixed,  the  operator  assumes 
a  position  back  of  the  patient  to  apply  the  tractile  movement. 

If  the  apical  end  of  the  root  of  one  of  these  teeth  fractures 
during  the  operation,  and  the  operator  observes,  as  the  tooth 
leaves  the  socket,  that  the  part  remaining  is  only  a  small  piece, 
and  if  the  surrounding  alveolar  process  is  normal,  it  is  not 
advisable  to  reapply  the  forceps  in  an  attempt  to  secure  this 
small  remaining  fragment.  If  no  pathologic  condition  exists  at 
the  apex  of  the  root,  or  if  a  bridge  is  not  to  be  made  to  fill  the 
space,  this  unextracted  part  should  be  left  undisturbed,  as  it  will 


220  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

not  iisiuilly  give  any  fm-ther  trouble,  and  it  will  be  more  readily 
released  when  the  alveolus  has  been  reduced  by  resorption. 

If,  however,  conditions  make  it  necessary  to  remove  the  un- 
extracted  part,  the  operator  examines  the  extracted  tooth  to 
determine  the  size  of  the  part  remaining.  He  then  selects  a  bur 
of  a  size  corresponding  to  that  of  the  remainder  of  the  root,  and, 
inserting  the  bur  into  the  socket  and  on  the  root  (Fig.  104),  the 
remaining  part  is  burred  away.  Care  should  be  taken  to  keep 
the  bur  in  line  with  the  axis  of  the  root,  so  that  cutting  into  the 
alveolus  may  be  avoided. 

INFERIOR  FIRST  AND  SECOND  MOLARS. 

The  extraction  of  the  inferior  first  molar  is  unfortunately  very 
common.  Its  early  eruption  subjects  it  to  all  the  inattention 
and  abuses  of  childhood,  and,  as  it  erupts  before  the  loss  of  any 
of  the  deciduous  teeth,  it  is  frequently  mistaken  for  them.  If  it 
is  attacked  by  caries,  the  care  of  it  is  often  neglected  with  the 
belief  that  it  will  be  replaced,  and  that  it  is  an  unnecessary  ex- 
pens^.for  a  child  to  have  its  teeth  kept  in  condition  for  mastica- 
tion. If  this  tooth  is  attacked  by  caries,  every  effort  should  be 
made  to  retain  it,  as  the  relation  of  the  inclined  i)lanes  of  the 
cusps  of  the  first  permanent  molars  establishes  and  fixes  the  re- 
lation of  the  inferior  arch  to  the  superior  arch  during  the  time 
all  of  tlie  deciduous  teeth  are  being  replaced  by  the  permanent 
ones  when  the  latter  are  normally  erupted  and  left  undisturbed. 
When,  however,  extraction  becomes  imperative,  the  operation,  in 
addition  to  being  usually  difficult,  owing  to  the  commonly  ad- 
vanced state  of  decay,  is  often  attended  by  unavoidable  fracture 
of  its  crown.  Fig.  105  shows  the  various  types  of  inferior  first 
and  second  molars  that  are  usually  seen. 

Position  of  Patient  and  Operator. — The  position  of  the  patient 
in  the  chair  and  that  of  the  operator  is  as  described  for  extract- 
ing inferior  teeth  (page  96).  When  operating  on  the  left  side 
of  the  arch,  the  head  of  the  patient  is  turned  slightly  to  the  right. 
The  left  arm  of  the  oiierator  is  brought  to  the  left  side  of  the 
head.  The  index  finger  is  v)laced  at  the  corner  of  the  mouth, 
retracting  the  cheek;  the  second  finger  depresses  the  lower  lip; 
flic  third  and  fourth  fingers,  with  the  thumb,  are  placed  be^ow 
the  jaw  (Fig.  106). 


IXFERIOR  FIRST  AND  SECOND  MOLARS 


221 


Fig  105.— Tvpes  of  inferior  first  and  second  molars.  First  row— tirst  four  teeth,  buccal 
surface  of  first  molars;  second  four  teeth,  buccal  surface  of  second  molans  becond 
row— first  four  teeth,  lingoial  surface  of  first  molars;  second  four  teeth,  lingual 
surface  of  second  molars.  Third  row— first  four  teeth,  mesial  surface  of  first 
molars;  second  four  teeth,  mesial  surface  of  second  molars.  Fourth  row— first 
four  teeth,  distal  surface  of  first  molars;  second  four  teeth,  distal  surface  of  second 
molars. 


000 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


When  operating  on  the  right  side  of  the  arch,  the  head  of  the 
patient  is  also  turned  slightly  to  the  right.  The  left  hand  of  the 
operator  is  brought  further  toward  the  front  of  the  mouth.  The 
index  finger  is  placed  along  the  lingual  surface  of  tlie  right  arch. 


Fig.  106. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
forceps  to  an  inferior  molar  on  the  left  side  of  the  arch.  Illustration  shows  the 
application  of  forceps  (Standard  No.  7)  to  the  inferior  left  first  molar. 

the  second  finger  depresses  the  lower  lip,  and  the  third  and 
fourth  fingers  are  placed  below  the  jaw  (Fig.  107). 

Forceps. — Standard  forceps  No.  7  (Fig.  8),  which  are  designed 
for  the  inferior  molars,  are  so  constructed  that  they  are  adapt- 
able to  both  sides  of  the  arch,  and  their  use  is  indicated  for  the 


INFERIOR  FIRHT  AXD  SECOND  MOLARS 


223 


extraction  of  all  inferior  first  and  second  molars  where  enough 
of  the  buccal  and  lingual  surfaces  of  the  tooth  remains  to  allow 
the  forceps  to  be  securely  adjusted. 

For  some  years  the  author's  experience  with  Standard  forceps 


Fig  107  —Position  of  the  operator's  hands  and  disposition  of  the  fingej-s  ^^'^en  applying 
forceps  to  an  inferior  Aiolar  on  the  right  side  of  the  arch  Illustra  ion  shows  the 
application  of  forceps  (Standard  No.  7)  to  the  inferior  right  first  molai. 

No.  7— or,  in  fact,  with  any  of  the  various  other  forceps  designed 
for  the  inferior  molars— was  not  entirely  satisfactory  on  account 
of  the  difficulty  of  properly  gauging  the  amount  of  force  to  be 
exerted,  and  at  the  same  time  keeping  the  beaks  under  perfect 
control,  while  applying  the  downward  pressure  or  wedge  move- 


224  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

meiit  of  extraction.  Q'lie  defects  of  this  iiistriuneiit  have,  how- 
ever, been  largely  overcome  with  the  improved  Standard  forceps 
No.  7  (Fig.  13)  described  on  page  27.  With  these  improved  for- 
ceps, properly  used,  the  inferior  molars  should  in  a  majority  of 
cases  be  delivered  in  their  entirety.  This  instrnment  should  not, 
however,  be  used  without  a  proi)er  regard  for  the  conservation 
of  the  tissues,  as  the  handles,  on  account  of  their  improved 
shape,  fit  so  snugly  into  the  palm  of  the  hand  when  the  beaks  are 
in  position  on  the  tooth  that  the  amount  of  force  that  can  be 
applied  is  limited  only  by  the  strength  of  the  operator. 

In  the  description  of  the  technic  for  the  extraction  of  the  in- 
ferior first  and  second  molars.  Standard  forceps  No.  7  (Fig.  8) 
are  the  forceps  referred  to,  as  they  are  the  best  instruments  regu- 
larly manufactured  for  the  extraction  of  these  teeth.  If  it  is 
desired  to  utilize  the  added  advantage  of  the  improved  Standard 
forceps  No.  7  (Fig.  13),  described  above  as  an  imi)rovement  on 
the  regular  Standard  forceps  No.  7,  such  advantage  may  be  se- 
cured by  altering  the  handles  of  the  regular  forceps  to  conform 
to  the  shaj^e  of  the  improved  force]:)s,  which  may  then  be  advan- 
tageously used  in  nearly  all  cases  where  the  regular  Standard 
forceps  No.  7  are  indicated. 

Standard  forceps  No.  6  (Fig.  7)  are  used  for  the  extraction  of 
these  teeth  where  they  are  not  very  firmly  attached;  or  where 
the  remaining  surface  of  the  crown  on  the  mesial  or  distal  side 
is  strong  enough  to  allow  their  adjustment,  but  not  enough  struc- 
ture remains  for  the  application  of  Standard  forceps  No.  7;  or 
where  only  the  roots  remain. 

Some  operators  advocate  the  use  of  the  cowhorn  forceps  for 
extracting  the  inferior  molars,  and  especially  for  extracting  the 
first  molar.  The  api)lication  of  the  cowhorn  forceps  is  not, 
however,  so  generally  practicable  as  is  that  of  Standard  forceps 
No.  7,  as  the  former  are  indicated  only  where  the  roots  are  not 
markedly  separated,  and  even  in  such  case  Standard  forceps 
No.  7  are  the  better  instrument.  The  great  disadvantage  of 
using  the  cowhorn  forceps  is  the  uncertainty  of  the  outcome  of 
the  operation,  as  in  the  application  of  force  it  is  impossible  to 
definitely  ascertain  whether  process  is  being  broken  down  or 
tooth  attachment  broken  up.  A  change  of  instrument  becomes 
necessary  when  any  resistance  is  encountered,  and  there  is  then 
also  a  lack  of  control  over  the  tooth  when  it  leaves  the  socket, 


INFERIOR  FIRST  AND  SECOND  MOLARS  225 

the  latter  feature  being  very  dangerous  when  the  patient  is 
under  a  general  cinosthetic. 

Order  of  Extraction. — As  in  the  case  of  the  superior  first 
molar  (page  157),  the  tooth  anterior  and  posterior  to  the  inferior 
first  molar  should  be  extracted  first  where  all  three  of  these 
teeth  are  to  be  removed,  especially  when  the  first  molar  is  firmly 
supported.  Where  the  third  molar  is  also  to  be  extracted,  and 
the  second  molar  is  to  serve  as  a  fulcrum,  the  second  is  never 
extracted  in  advance  of  the  third  molar. 

Application  of  Forceps. — The  forceps  having  been  selected, 
application  should  be  made  slowly  and  cautiously,  and  the  beaks 
are  opened  gradually  as  they  approach  the  tooth.  Where  Stand- 
ard forceps  No.  7  are  used,  one  beak  is  first  applied  to  the 
lingual  wall  of  the  tooth,  followed  by  the  application  of  the 
opposing  beak  to  the  buccal  wall.  When  both  beaks  are  in 
position,  they  are  sent  down  under  the  free  margin  of  the  gum 
to  the  marginal  edge  of  the  alveolus,  keeping  them  in  a  direct 
line  with  the  axis  of  the  tooth,  and  taking  care  that  the  points  of 
the  beaks  are  between  the  two  roots.  This  application,  exe- 
cuted with  sufficient  pressure,  is  of  great  value,  and  should  be 
depended  on  to  materially  assist  in  the  dislodgment  of  the  tooth. 
Application  with  the  improved  Standard  forceps  is  made  in  the 
same  manner,  but  much  better  control  of  the  beaks  is  had  with 
this  instrument  than  with  the  regular  Standard  forceps  No.  7. 

It  is  not  unusual  to  find  the  crown  of  one  of  these  teeth  inclined 
mesially  where  the  tooth  anterior  to  it  has  been  missing  for  some 
time.  Where  this  condition  exists,  such  an  instrument  must  be 
used  as  will  permit  the  application  to  be  made  in  line  with  the 
axis  of  the  tooth.  Whenever  possible  under  these  circumstances. 
Standard  forceps  No.  7  should  be  used;  but  if  the  inclination 
is  so  great  that  these  forceps  cannot  be  applied  with  the  beaks 
in  line  with  the  axis  of  the  tooth,  Standard  forceps  No.  2  or  No.  4 
are  employed.  When  using  either  of  the  latter  forceps,  the 
operator  assumes  a  position  in  front  of  the  patient  for  their 
application. 

Alveolar  Application  of  Forceps. — An  alveolar  application  is 
not  practicalile  where  the  alveolar  structure  surrounding  these 
teeth  is  in  a  normal  state,  and  should  be  made  only  when  the 
margin  of  the  process  is  affected  by  caries  and  the  carious  condi- 
tion will  permit  a  limited  alveolar  application  being  made  to  the 


226  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

roots  of  these  teeth  with  Standard  forceps  No.  6,  but  should 
seldom  be  attempted  with  Standard  forceps  No.  7. 

Extraction  Movements. — Practically  the  same  extraction  move- 
ments apply  to  both  the  first  and  second  molar,  modified  only 
where  the  anterior  border  of  the  ramus  and  the  external  oblique 
line  rising  from  it  are  to  the  disto-buccal  side  of  the  second 
molar,  in  which  case  the  buccal  movement  cannot  be  executed  as 
freely  with  the  second  molar  as  with  the  first  molar,  and  the 
main  extraction  movements  for  the  second  molar  are  then  to  the 
lingual  side,  combined  with  the  wedge  movement  that  is  made 
by  the  downward  pressure. 

When  the  forceps  have  been  securely  adjusted  to  one  of  these 
teeth,  as  shown  in  Fig.  108,  A,  illustrating  Standard  forceps 
No.  7  applied  to  the  inferior  left  first  molar,  the  first  extraction 
movement  is  executed  by  bringing  the  tootli  slightly  lingually 
(Fig.  108,  B),  followed  by  directing  the  tooth  with  about  the 
same  force  buccally  (Fig.  108,  C).  If  these  movements  fail  to 
loosen  the  tooth,  the  lingual  movement  is  repeated  more  forcibly 
(Fig.  108,  D),  and  is  followed  by  bringing  the  tooth  with  the 
same  increased  force  to  the  buccal  side  (Fig.  108,  E),  when  the 
tooth  is  extracted  with  a  tractile  movement  upward  in  line  with 
its  original  position  (Fig.  108,  F),  provided  the  tooth  is  not 
crowded  by  the  approximating  teeth  or  its  roots  are  not  diver- 
gent. If  continued  resistance  is  encountered  and  the  alveolar 
process  is  unusually  heavy,  which  condition  is  the  most  common 
cause  of  the  greater  resistance,  the  beaks  are  sent  further  down 
on  the  tooth  with  slightly  increased  pressure  on  the  handle  of 
the  forceps,  which  serves  the  double  purpose  of  adding  the 
wedge  movement  and  permitting  greater  force  to  be  used  in  the 
linguo-buccal  movements  without  causing  fracture,  as  it  dimin- 
ishes the  leverage  on  the  neck  of  the  tooth  by  applying  the  force 
nearer  the  point  of  resistance.  K  the  root  is  fused,  which  is 
frequently  the  case,  especially  with  the  second  molar,  the  wedge 
movement  will  often  loosen  the  tooth  sufficiently  to  allow  the 
tractile  movement  to  be  applied.  If,  however,  the  latter  extrac- 
tion movement  does  not  sufficiently  loosen  the  tooth  for  the  ap- 
plication of  the  tractile  movement,  the  extraction  movements 
previously  described  must  be  continued  until  the  final  tractile 
movement  is  possible. 

Where  the  two  roots  of  these  teeth  diverge  to  such  an  extent 


INFERIOR  FIRST  AND  SECOND  MOLARS 


227 


D 


E 


F 


Fig-.  108. — Extraction  movements  for  inferior  first  and  second  molars.  A,  forceps 
(Standard  No.  7)  applied  to  the  inferior  left  first  molar;  B,  first  movement  to  the 
lingual  side;  C,  reversed  movement  to  the  buccal  side;  D.  E,  movements  B  and  € 
more  forcibly  repeated;  F,  tractile  movement  upward  in  line  with  the  original  posi- 
tion of  the  tooth. 


228  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

that  the  distance  between  them  is  markedl}'  greater  at  the  apical 
third  than  at  the  gingival  third,  which  condition  is  very  preva- 
lent with  the  first  molar  and  uncommon  with  the  second,  there 
is  always  danger  of  loosening  one  or  both  of  the  adjacent  teeth 
when  removing  the  affected  tooth  from  its  socket.  The  adjacent 
teeth  should  be  carefully  observed  during  the  execution  of  the 
tractile  movement,  especially  if  the  preliminary  examination 
revealed  the  fact  that  they  are  not  firmly  adherent  to  the  sup- 
porting tissues.  If  any  movement  of  either  of  these  teeth  is 
discerned,  the  tractile  movement  in  the  direction  of  the  original 
position  of  the  affected  tooth  is  immediately  discontinued,  and, 
while  supporting  the  disturbed  tooth  with  the  thumb  of  the  left 
hand,  the  tooth  is  carried  buccally  far  enough  so  that,  wheti  it  is 
finally  drawn  from  its  socket  by  the  tractile  movement  that  is 
again  apiDlied,  its  divergent  roots  will  not  interfere  with  the  ap- 
proximating teeth.  In  executing  the  tractile  movement  on  a 
tooth  with  divergent  roots,  no  attempt  should  ever  be  made  to 
carry  the  tooth  from  its  position  by  sheer  force  alone,  but  the 
linguo-buccal  movement  should  be  continued  in  combination  with 
the  tractile  movement  for  the  jjurpose  of  ascertaining  the  direc- 
tion of  least  resistance.  If  these  combined  movements  are  cor- 
rectly executed,  the  flexibility  of  the  roots  and  also  of  the  process, 
which  factor  they  possess  in  a  ratio  corresponding  to  the  per- 
centage of  mineral  matter  they  contain,  may  be  utilized  to  its 
fullest  extent  and  a  tooth  difficult  of  extraction  be  removed  with- 
out fracture  of  roots  or  process. 

On  completion  of  the  extraction,  the  dilated  socket  may  be 
readily  reduced  by  applying  pressure  to  both  of  its  sides  with 
the  thumb  and  index  finger,  as  shown  in  Fig.  187,  and  pressure 
should  also  be  applied  on  the  approximating  teeth  to  ascertain 
whether  they  are  in  normal  position.  If  both  adjacent  teeth  are 
observed  to  be  distributed  by  any  tractile  movement,  it  is  prefer- 
able to  fracture  the  crown  of  the  tooth  to  be  extracted  by  exerting 
a  forcible  pressure  on  the  beaks  of  the  forceps  and  separating 
the  roots,  as  described  in  the  case  of  fracture  (page  244),  after 
which  each  root  is  separately  removed. 

Occasionally  the  inferior  first  or  second  molar  is  supplied  with 
a  third  root,  which  can  more  properly  be  classed  as  a  super- 
numerary root  than  a  bifurcation  of  either  of  the  other  roots. 
This  supernumerary  root  is  conical  in  shape,  small,  and  rather 


INFERIOR  FIRST  AND  SECOND  MOLARS  229 

long  compared  with  its  diameter.  It  usually  rises  from  the 
crown  of  the  tooth  a  little  below  the  neck,  being  located  either 
slightly  distally  of  the  mesial  root  or  slightly  mesially  of  the 
distal  root,  and  may  appear  on  either  the  buccal  or  lingual  side 
of  the  tooth. 

The  presence  of  this  extra  root,  which  is  not  perceptible,  is 
not  suspected  until  extraction  is  undertaken  and  unusual  resist- 
ance is  encountered.  When,  however,  its  presence  is  indicated, 
the  principal  extraction  movement  is  made  to  the  side  opposite 
to  the  extra  root,  and  it  will  be  found  to  be  exceedingly  difficult 
to  remove  this  root  intact  with  the  tooth.  In  case  of  its  fracture, 
the  operation  described  for  removing  fractured  parts  with 
Standard  forceps  No.  6  or  with  the  elevator  (page  244)  is  appli- 
cable for  its  removal. 

Displacement. — Inferior  first  and  second  molars  are  occasion- 
ally partially  displaced  buccally  or  lingually,  but  the  author  has 
never  seen  either  tooth  in  complete  displacement  to  either  side 
of  the  arch  of  which  it  forms  a  component  part.  In  partial 
displacemeut,  when  the  space  on  the  narrowed  side  will  permit 
the  beaks  of  Standard  forceps  No.  7  (Fig.  8)  to  be  applied,  the 
use  of  these  forceps  is  preferred,  but,  if  their  application  is  not 
practicable,  Standard  forceps  No.  G  (Fig.  7)  should  be  substi- 
tuted. The  latter  forceps  are  used,  however,  only  to  gain  space 
for  the  adjustment  of  Standard  forceps  No.  7.  The  first  extrac- 
tion movement  is  made  to  the  side  to  which  the  tooth  is  displaced, 
and  then  reversed  toward  the  opposite  side  as  far  as  the  space 
will  permit.  These  two  movements  are  repeated,  applying  in- 
creased force  to  the  first  movement,  and,  if  necessary,  using  in 
conjunction  the  wedge  movement,  as  described  (page  226),  until 
the  tooth  is  loosened  from  its  attachment,  when  the  extraction  is 
completed  by  the  tractile  movement  as  nearly  as  possible  in  line 
with  its  original  position. 

Caries  on  Buccal  or  Lingual  Surface. — Where  caries  involves 
the  buccal  or  lingual  surface  of  one  of  these  teeth,  and  the  un- 
atfected  surface  is  reasonably  strong.  Standard  forceps  No.  7  or 
—  especially  in  such  cases — the  improved  Standard  forceps  No.  7 
are  indicated.  One  beak  should  l)e  first  applied  to  the  involved 
surface,  and,  if  the  decay  extends  below  the  gum  margin,  this 
beak  is  sent  quite  a  distance  down  on  this  surface  to  gain  a  firm 
adjustment,  after  which,  if  the  margin  of  alveolus  is  partially 


230  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

carious,  judicious  alveolar  application  may  be  made  to  the 
affected  surface.  The  first  extraction  movement  is  made  to  the 
carious  side,  and,  if  this  movement  disengages  the  beak  on  the 
weakened  surface,  the  beak  should  be  sent  further  down  on  that 
surface  before  bringing  the  tooth  slightly  in  the  opposite  direc- 
tion. These  movements  should  be  continued,  with  the  more 
forcible  one  always  to  the  side  attacked  by  caries,  until  the  tooth 
is  loosened  from  its  attachment,  when,  with  a  movement  to  the 
weakened  side,  it  is  delivered  from  the  socket  by  the  tractile 
movement. 

Caries  on  Mesial  or  Distal  Surface. — Where  there  is  a  cavity 
on  the  mesial  or  distal  surface  of  one  of  these  teeth,  and  there  is 


Fig.  109. — Inferior  first  molar.     Di.stal   .surface   destroyed   by  caries. 

enough  structure  on  the  lingual  and  buccal  surfaces  for  Standard 
forceps  No.  7  to  be  securely  adjusted,  this  instrument  should  be 
employed,  and  the  same  technic  applied  as  when  the  crown  is 
intact  (page  226).  Where  either  of  these  surfaces  is  involved  by 
caries  to  such  an  extent  that  the  beaks  of  the  forceps  can  be 
adjusted  only  to  the  mesial  or  distal  half  of  the  neck  of  the  tooth, 
and  no  supjDort  can  be  had  from  the  involved  side,  Standard 
forceps  No.  6  should  be  used.  In  Fig.  109  is  shown  a  first  molar 
with  the  distal  side  of  its  crown  destroyed  by  caries.  In  such 
case  Standard  forceps  No.  6  should  be  applied  to  the  mesial  half 
of  the  crown,  and  the  extraction  movements  made  in  the  same 


INFERIOR  FIRST  AND  SECOND  MOLARS  231 

manner  as  when  the  crown  is  intact.  Usually  the  distal  half, 
if  the  two  roots  are  partially  united,  will  be  carried  out  of  its 
socket  with  the  mesial  root ;  but,  if  this  is  not  accomplished,  it 
will  usually  be  loosened  and  is  removed  with  the  same  forceps. 
If  this  adjustment  cannot  be  made,  the  author's  lower  root  ele- 
vator (Fig.  18)  is  employed  to  extract  it  in  the  same  manner  as 
this  elevator  is  used  for  the  extraction  of  roots  (page  233).  The 
same  method  of  operation  in  a  reversed  order  prevails  where  the 
tooth  has  been  attacked  by  caries  on  the  mesial  side. 

Where  caries  involves  the  distal  surface  of  the  second  molar 
and  the  third  molar  is  missing  from  the  arch  (Fig.  110),  it  is 


Fig.  110. — Inferior  second  molar.  Distal  surface  destroyed  by  caries,  with  the  third 
molar  missing.  In  such  case  the  Lecluse  elevator  (Fig.  21)  may  be  used  preceding 
the  application  of  the  forceps. 

advisable  in  most  cases  to  first  loosen  the  tooth  with  an  elevator, 
as  this  procedure  simplifies  the  operation  and  also  decreases  the 
liability  of  a  fracture.  Here  the  blade  of  the  Lecluse  elevator 
(Fig.  21)  is  applied  to  the  mesial  surface  of  the  crown  or  the 
neck  of  the  second  molar,  using  the  distal  surface  of  the  first 
molar  as  a  fulcrum.  The  blade  is  sent  between  the  two  teeth 
with  considerable  pressure  and  acts  as  a  wedge.  If  this  fails  to 
loosen  the  tooth,  the  blade  is  directed  slightly  distally  (Fig.  Ill) 
by  turning  the  upper  end  of  the  handle  in  that  direction,  but  the 


232  EXTRACTION  TECHNIC  OE  INEERIOR   TEETH 

amount  of  force  that  may  be  applied  is  slight  compared  with  the 
amount  that  may  be  exerted  when  this  instrument  is  employed  on 
the  inferior  third  molar.  The  elevator  is  used  merely  to  loosen 
the  tooth,  and  as  soon  as  this  is  done  the  forceps  are  applied  to 
complete  the  operation.  If,  when  using  the  elevator  in  this  man- 
ner, rather  firm  resistance  is  encountered  while  executing  the 
distal  movement,  no  attempt  should  be  made  to  force  this  move- 
ment, as  a  fracture  will  result.  Resistance  to  this  movement  of 
the  elevator  is  indicative  of  fused  roots  or  roots  that  are  not  in- 


Fig    111.— Same  subject  as  Fig.  110.     Illustration  shows  the  extraction  movement  with 
the  Lecluse  elevator  (Fig.  21),  the  blade  of  the  elevator  directing  the  tooth  distally. 

clined  distally,  and  in  either  condition  the  use  of  the  elevator 
should  1)0  discontinued  and  the  forceps  applied. 

Two  Roots  'Umted—Fo)ce2)s  In (Ucated.— Where  the  two  roots 
of  a  first  or  second  molar  remain  and  they  are  rather  firmly 
united  to  each  other,  are  of  considerable  size,  and  the  part  re- 
maining above  the  healthy  alveolar  process  is  sufficiently  strong 
to  allow  Standard  forceps  Xo.  7  (Fig.  8)  to  be  securely  adjusted, 
this  instrument  is  applied  and  the  extraction  movements  are 
executed  as  though  the  crown  were  intact.  Where  either  the 
mesial  or  distal  root  has  been  weakened  by  caries  to  such  an 
extent  that  Standard  forceps  No.  7  cannot  be  securely  adjusted, 


INFERIOR  FIRST  AND  SECOND  MOLARS  233 

as  in  the  case  where  the  crown  of  the  tooth  is  extensively  in- 
volved by  caries  on  the  mesial  or  distal  surface  (page  230),  and 
one  of  the  roots  possesses  enough  firm  structure  to  allow  Stand- 
ard forceps  No.  6  (Fig.  7)  to  be  adjusted,  this  instrument  is 
applied  to  that  root  and  the  extraction  movements  are  executed. 
The  other  root,  as  in  the  case  where  these  forceps  are  adjusted 
to  the  mesial  or  distal  half  of  the  crown  (page  230),  will  accom- 
pany the  extracted  root;  but,  if  it  does  not  come  out  with  the 
extracted  root,  it  is  usually  loosened,  and  can  be  removed  with 
the  same  forceps  or  with  an  elevator. 

Elevator  Indicated. — AVhere  the  two  roots  remain,  and  they 
are  not  fused  and  only  slightly  united,  and  caries  has  destroyed 
them  to  such  an  extent  on  the  buccal  or  lingual  surface  that  their 
removal  with  the  forceps  is  uncertain  for  the  want  of  structure  to 
secure  a  firm  application,  the  elevator  should  be  selected  for 
their  removal.  Either  the  Knott  (Fig.  17)  or  the  author's  lower 
root  elevator  (Fig.  18),  preferably  the  latter,  should  be  used,  as 
the  blade  of  either  of  these  elevators  is  broader  and  stronger, 
and  better  adapted  to  the  strain  that  would  naturally  be  imposed 
on  it  when  applying  a  leverage  on  these  roots,  than  that  of  the 
Cryer  elevator  (Fig.  24),  which  is  more  appropriately  used  on 
the  teeth  anterior  to  the  first  molar.  Where  the  tooth  is  on  the 
right  side  of  the  arch,  the  short-shank  elevator  is  used;  where 
it  is  on  the  left  side,  if  the  roots  are  not  firmly  attached,  the 
long-shank  elevator  (Fig.  20)  is  used,  with  the  operator  in  posi- 
tion on  the  right  side  of  the  patient,  the  adjustment  being  made 
at  the  bifurcation  on  the  lingual  side.  Where  a  tooth  is  on  the 
left  side  of  the  arch,  and  its  attachment  is  so  firm  as  to  make 
repeated  application  possible,  it  is  advisable  to  use  the  short- 
shank  elevator,  the  operator  in  such  case  assuming  a  position  on 
the  left  side  of  the  patient  or  stand  on  the  right  side  and  lean 
across  the  front  of  the  patient,  turning  the  latter 's  head  toward 
the  right.  When  using  the  author's  lower  root  elevator,  the 
point  of  the  blade  is  applied  between  the  tooth  or  root  and  the 
alveolar  process,  with  the  concave  side  of  the  blade  toward  the 
part  to  be  dislodged,  and  the  instrument  is  held  so  that  the  point 
of  the  blade  is  directed  as  nearly  as  possible  toward  the  apex  of 
the  root.  Pressure  carefully  applied  will  force  the  l)lade  be- 
tween the  root  and  the  alveolar  process,  when  a  slight  turn  of 
the  handle  will  cause  the  point  of  the  blade  to  engage  the  root. 


234  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

The  convex  side  of  the  blade,  resting  on  the  process  or  on  another 
root  as  a  fulcrum,  completes  the  lever  arrangement,  and  the  tooth 
is  pried  from  its  position  if  this  desired  result  has  not  already 
been  accomplished  by  the  wedge  force  of  the  application. 

In  applying  the  author's  lower  root  elevator  to  extract  the 
roots  of  an  inferior  first  or  second  molar  where  the  roots  are  not 
firmly  united,  the  point  of  the  blade  is  presented  buccally  at  the 
bifurcation  of  the  roots  (Fig.  112),  and  force  is  applied  lingually 
and  downward,  which  will  direct  the  blade  toward  the  median 
line  of  the  tooth  and  separate  the  two  roots  (Fig.  113).  This 
operation  alone  will  usually  be  sufficient  to  dislodge  the  distal 
root,  but,  if  it  is  not  dislodged,  the  point  of  the  blade,  without 
being  removed  from  its  position,  is  applied  to  the  distal  root  in 
the  manner  described  above  for  the  application  of  the  elevator, 
and  the  root  is  removed  from  its  socket  (Fig.  114).  Wliere  the 
parts  anterior  to  the  mesial  root  are  suitable  for  a  fulcrum,  the 
elevator  is  applied  to  the  mesial  surface  of  this  root  (Fig.  115), 
and  it  is  removed  by  the  same  technic  of  operation. 

Where  there  is  a  cavity  on  the  distal  surface  of  the  tooth  an- 
terior to  the  one  to  be  extracted,  such  anterior  tooth  cannot  be 
utilized  as  a  fulcrum,  and  a  mesial  application  cannot  usually  be 
made  under  such  condition.  In  such  case,  as  soon  as  the  distal 
root  has  been  extracted,  the  mate  to  the  elevator  just  used  is 
applied  to  the  distal  surface  of  the  mesial  root,  and,  if  the  septum 
separating  the  two  roots  is  very  heavy,  it  is  utilized  as  a  fulcrum 
to  complete  the  extraction;  but  where  the  septum  is  thin  or 
weakened  by  caries,  the  operation  is  performed  in  the  same  man- 
ner as  when  operating  under  a  like  condition  with  the  two  roots 
separated  (page  240). 

When  operating  with  the  author's  lower  root  elevator  (Fig.  18) 
on  the  left  side  of  the  arch,  the  position  of  the  operator  should 
be  changed  to  that  side  of  the  patient,  except  where  the  at- 
tachment of  the  roots  is  not  very  firm,  in  which  latter  case  the 
author's  special  lower  root  elevator  (Fig.  20)  may  be  used  to 
advantage  as  a  time  saver. 

Where  the  two  roots  of  the  first  molar  cannot  be  separated 
with  the  author's  lower  root  elevator,  and  if  the  attachment  is 
not  unusually  firm,  the  extraction  can  often  be  accomplished  by 
applying  the  point  of  the  blade  on  the  buccal  side  of  the  tooth 
well  under  its  crown  and  at  the  bifurcation  of  the  two  roots. 


INFERIOR  FIR8T  AND  SECOND  MOLARS 


235 


Fig.  112. — Crown  of  an  inferior  fir.st  molar  destroyed  tay  caries,  with  the  roots  partially 
united.  Illustration  shows  the  application  of  the  author's  lower  root  elevator  No.  1 
(Fig-.  18)  from  the  buccal  side,  with  the  point  of  the  blade  inserted  at  the  bifur- 
cation. 


236 


EXTRACTION  TECHNIC  OF  INFERIOR   TEETH 


Fig.  1]3. — Same    subject   as    Fig.    112.     Illustration    shows    the    blade    of    the    elevator 
directed  midway  between  the  roots  and  separating  them. 


INFERIOR  FIRST  AND  SECOND  MOLARS 


237 


TTip-    114      Samp  subiect  as   Fiss    112,   113.     Illustration  shows  the  method  of  removing 

^"  the   distaT  root      The  uppfi    end  of  the  handle   of   the   elevator   is  turned   mesially 

the   Doint  of  the  blfde   engages    the  mesial  surface   of   the   distal   root,    the  mesial 

root'berng  Led  as  a  fufcrurr^,  and  the  turning  of  the  handle  raises  the  root  from 

the  socket. 


238 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


Fig.  115.— Same  subject  as  Figs.  112,  113,  114.  Illustration  shows  the  method  of  remov- 
ing the  mesial  root  after  the  distal  root  has  been  removed.  The  blade  of  the  ele- 
vator IS  inserted  into  the  interproximal  space  between  the  root  and  the  second 
bicuspid,  the  latter  being  used  as  a  fulcrum. 


INFERIOR  FIRST  AND  SECOND  MOLARS  239 

The  adjustment  having  been  secured,  pressure  is  directed  against 
the  tooth  lingually,  with  which  is  combined  a  lifting  force  toward 
the  occlusal.  If  resistance  is  still  encountered,  adjustment  of 
the  point  of  the  blade  is  made  further  under  the  tooth,  which 
applies  the  two  forces  common  to  this  elevator,  and  the  lifting 
movement  is  again  executed.  If  these  movements  are  skillfully 
performed,  excellent  results  can  often  be  accomplished  by  this 
method  of  operation. 

In  extracting  an  inferior  second  molar  where  the  third  molar 
is  present,  the  author's  lower  root  elevator  should  be  applied, 
and  an  adjustment  secured  on  the  mesio-buccal  surface,  using  the 
first  molar  or  the  alveolus  as  a  fulcrum.  The  teclmic  of  opera- 
tion applicable  to  the  use  of  this  elevator  (page  233)  will  usually 
release  the  roots;  and,  if  it  does  not,  a  lifting  movement  is  ap- 
plied, which  will  complete  the  extraction  in  a  majority  of  such 
cases.  This  method  is  especially  indicated  when  operating  on 
this  tooth  where  its  roots  are  fused.  AVhere  this  procedure  is 
not  practicable,  the  technic  of  operation  for  removing  these 
roots  when  a  fracture  has  occurred  should  be  followed  as  de- 
scribed on  page  244. 

Two  Roots  Separated — Forceps  Indicated. — Where  only  the 
roots  of  these  teeth  remain,  and  they  are  separated,  but  accessi- 
ble, and  the  parts  projecting  above  the  alveolar  process  are 
reasonably  strong.  Standard  forceps  No.  6  should  be  employed, 
applying  them  first  to  the  root  most  accessible  and  with  the 
strongest  structure.  Other  conditions  being  equal,  the  distal 
root  has  the  preference.  In  Fig.  116  are  shown  the  forceps 
applied  to  the  distal  root  of  the  first  molar.  When  the  forceps 
have  been  securely  adjusted,  the  extraction  movements  are  in 
the  main  the  same  as  though  the  crown  were  intact.  After  one 
root  has  been  removed,  the  forceps  are  immediately  applied  to 
the  other  root  before  it  has  been  obscured  by  hemorrhage,  and 
is  extracted  in  the  same  manner. 

Where  only  one  root  remains,  the  same  technic  of  operation  is 
applied  as  where  the  roots  are  separated,  using  either  Standard 
forceps  No.  6  or  the  author's  lower  root  elevator. 

Where  both  roots  are  separated,  and  only  one  root  is  to  be 
extracted,  the  other  root  to  be  used  as  an  abutment  for  an  arti- 
ficial crown,  it  is  preferable  to  remove  the  former  with  the  for- 
ceps.   If  an  elevator  is  employed,  an  adjacent  tooth  should  be 


240  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

used  as  a  fulcrum,  as  the  root  to  be  crowned  must  not  be  used 
for  this  purpose. 

Elevator  Indicated. — Where  the  two  roots  are  separated,  and 
their  lingual  and  buccal  surfaces  are  not  strong  enough  to  allow 
Standard  forceps  No.  6  to  be  securely  adjusted,  the  author's 
lower  root  elevator  should  be  used,  as  a  quicker  and  more 
effective  operation,  with  less  destruction  of  the  tissues,  can  be 
accomplished  with  this  instrument  than  with  the  forceps.  When 
the  two  roots  are  in  close  proximity,  and  their  approximating 
surfaces  have  not  been  weakened  too  greatly  by  caries,  the  ele- 


Fig.  116. — Standard  forceps  No.  6  applied  to  a  distal  root  of  an  inferior  first  molar. 

vator  is  applied  between  them,  the  same  technic  of  operation 
being  followed  as  described  for  0})erating  on  the  two  roots  when 
united  (page  233).  If  an  application  cannot  be  securely  made 
between  the  roots,  an  application  is  made  to  the  mesial  surface 
of  the  mesial  root  or  to  the  distal  surface  of  the  distal  root,  which- 
ever is  more  accessible  and  the  stronger,  taking  into  considera- 
tion at  the  same  time  the  most  available  fulcrum.  With  the 
first  molar  the  extraction  of  the  distal  root  is  favored,  as  a  better 
fulcrum  is  had  on  the  second  molar  than  on  the  second  bicuspid. 
With  the  second  molar  the  mesial  root  should  be  removed  in 


INFERIOR  FIRST  AND   SECOND  MOLARS 


241. 


^w^f.v^  ■ 


Fig.  117. — Same  subject  as  Figs.  112,  113,  114,  115.  Illustration  shows  the  method  of 
removing  the  mesial  root  by  distal  application  after  the  distal  root  has  been  re- 
moved. The  blade  of  the  elevator  is  inserted  into  the  empty  socket  created  by  the 
extraction  of  the  distal  root,  the  point  of  the  blade  cut.s  through  the  septum,  and 
the  turning  of  the  handle  extracts  the  root. 


242  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

advance  of  the  distal  root  where  conditions  will  permit,  as  the 
first  molar  is  a  better  fnlcrum  than  the  third.  The  elevator  is 
applied  as  described  for  the  nse  of  this  instrument  (page  233). 

Where  the  septum  supporting  the  two  roots  is  very  thin,  or 
where  it  has  been  weakened  by  caries,  and  one  of  the  roots  has 
been  removed,  the  remaining  root  is  extracted  by  inserting  the 
instrument  into  the  socket  of  the  extracted  root  (Fig.  117). 
This  method  obviates  changing  from  one  to  the  other  elevator,  as 
the  case  may  be.  For  example,  if  the  mesial  root  is  fragile  and 
the  distal  root  is  the  first  to  be  removed,  the  elevator  is  inserted 
into  the  socket  of  the  distal  root  at  about  its  middle  third;  the 
blade  is  directed  against  the  septum  supporting  the  two  roots, 
and  a  forcible  pressure  is  applied,  with  a  slight  turn  of  the 
instrument.  This  procedure  will  loosen  the  root  with  little 
injury  to  the  tissues,  and  it  is  then  removed  with  the  Derenberg 
tweezers.  The  order  of  extraction  of  the  two  roots  may  be  re- 
versed if  tlie  condition  of  the  distal  root  and  the  fulcrum  make 
the  reversed  [)r()ce(lure  the  more  favorable. 

Roots  Covered  by  Gum  Tissue. — Where  the  gum  tissue  over- 
lies the  roots,  and  Standard  forceps  No.  7  or  No.  6  can  be  ad- 
justed, either  of  these  forceps  may  be  used.  The  method  of 
spreading  the  gum  with  the  beaks  from  over  the  roots  is  the 
same  as  in  the  case  of  superior  central  incisor  (page  116).  Where 
an  adjustment  cannot  be  obtained  with  these  forceps,  or  to  adjust 
them  would  cause  too  great  destruction  of  tissue,  the  author's 
lower  root  elevator  should  be  used.  The  roots  are  uncovered 
with  the  blade  of  the  elevator  in  the  same  manner  as  when  the 
forceps  are  used.  If  the  gum  tissue  is  in  the  form  of  a  loose 
flap,  the  uncovering  is  readily  done;  but,  if  the  tissue  is  firmly 
adherent,  it  will  be  necessary  to  make  an  incision  to  permit  the 
elevator  to  be  applied. 

Deep-Seated  Roots. — Where  the  roots  of  these  teeth  are  deeply 
seated  and  the  alveolar  process  is  normal,  the  technic  of  opera- 
tion is  applied  as  described  for  fracture  cases  (page  241).  Where 
the  alveolus  has  been  weakened  by  caries,  the  roots  are  readily 
released  with  the  Cryer  elevator  (Fig.  24)  if  situated  on  the 
right  side  of  the  arch,  and,  if  on  the  left  side,  with  the  modified 
Cryer  elevator  (Fig.  25).  Fig.  118  shows  a  condition  frequently 
seen  in  connection  with  the  inferior  first  and  second  molars. 
Careful  judgment  must  be  used  by  the  operator  in  such  case,  and 


INFERIOR  FIRST  AND  SECOND  MOLARS  243 

the  operation  for  the  removal  of  the  roots  should  not  be  at- 
tempted until  after  the  existing  conditions  have  been  thoroughly 
outlined.  Often  in  these  cases  all  of  the  tooth  stimcture  that 
remains  is  a  frail  enamel  wall  of  the  crown,  with  just  enough 
dentine  at  the  neck  of  the  tooth  for  the  whole  shell  to  be  sup- 
ported only  by  the  gum  tissue,  and  the  pulp  chamber  is  filled 
with  a  very  vascular  polypus.  The  part  of  the  crown  remaining 
possesses  no  strength,  so  that  the  first  application  of  any  instru- 
ment will  crush  it.  If  such  condition  is  suspected,  it  is  advisable 
to  make  an  examination  with  the  explorer,  by  passing  it  below 
the  crown  at  several  points,  to  ascertain  whether  the  roots  are 


Fig.  118.— Inferior  first  molar  affected  witli  Fig.   119.— Same  .subject  as  Fig.  118.    Illus- 

extensive     caries.     Illu.=;tration     shows  tration    shows    the    condition    of    the 

the  remains  of  the  enamel  wall  of  the  hard  structure  and  roots. 
crown,  with  the  chamber  filled  with  a 
vascular  polypus. 

connected  with  the  crown.  Fig.  119  shows  an  outline  of  this 
condition  of  a  tootli  and  the  relation  of  the  crown  to  the  roots 
that  may  often  be  found  in  such  cases. 

If  an  area  of  tootli  structure  between  the  crown  and  roots  is 
destroyed  by  caries  and  the  surrounding  alveolar  process  is  cari- 
ous, the  two  roots  are  in  reality  entirely  separated  from  the  struc- 
ture above  and  are  deeply  seated.  The  operative  technic  in  such 
case  is  to  remove  the  outer  wall  of  the  crown  with  Derenberg 
tweezers,  or,  if  it  is  more  firmly  attached  to  the  gum  tissue,  with 
the  forceps.  The  crown  having  been  removed,  the  roots  are  ex- 
tracted with  the  author's  lower  root  elevator,  the  technic  of 


244  EXTRACTION  TECHNIC  OF  INFERIOR   TEETH 

operation  being  the  same  as  that  applicable  to  the  use  of  the 
elevator  for  the  extraction  of  two  roots  when  they  are  united  or 
separated,  as  the  case  may  be.  The  increased  difficulties  when 
operating  in  such  case  are  the  hemorrhage  induced  by  the  re- 
moval of  the  crown  and  the  fullness  of  the  gum  tissue  surround- 
ing the  roots,  which  greatly  obscures  the  field  of  operation. 

In  the  cases  described  there  is  always  considerable  carious 
alveolar  tissue,  and  the  after-treatment  of  the  socket  should  re- 
ceive careful  attention. 

Screw-Porte.— The  screw-porte  is  not  often  used  in  connection 
with  these  teeth,  and  is  indicated  in  very  rare  cases,  as,  for  ex- 
ample, where  the  distal  root  is  deeply  seated,  firmly  attached, 
and  inclined  enough  mesial  1 3^  to  be  accessible  with  the  Keith 
screw-porte. 

Impaction. — It  is  very  rare  to  find  one  of  these  teeth  impacted 
in  the  manner  that  occurs  with  the  inferior  third  molar.  Occa- 
sionally the  inferior  second  molar  is  partially  impacted,  and, 
when  such  case  is  found,  the  technic  of  operation  will  closely 
follow  that  described  for  partially  impacted  inferior  third  molar 
(Chapter  XI). 

Fracture — Ttro  Boots  United. — Where  a  fracture  of  an  inferior 
first  or  second  molar  occurs  while  Standard  forceps  No.  7  or 
No.  6  are  being  used,  and  if  by  a  misapplication  of  the  beaks  the 
fracture  occurs  above  the  marginal  ridge  and  this  ridge  is 
carious,  a  readjustment  of  the  particular  forceps  in  use  should  be 
made  to  complete  the  operation. 

In  making  a  reapplication  of  the  forceps  at  any  time  following 
a  fracture,  care  must  be  exercised  to  avoid  grasping  parts  of  the 
process  between  the  beaks  of  the  forceps  instead  of  the  fractured 
tooth,  and,  if  there  is  an  inclination  of  the  tooth,  to  see  that  the 
reapplication  is  made  in  line  with  its  axis. 

Where  a  fracture  is  low,  and  the  margin  of  the  alveolar  process 
projects  beyond  the  remaining  part  of  the  tooth  and  is  in  a  nor- 
mal state,  it  becomes  an  interfering  factor  and  hinders  the  reap- 
plication of  the  forceps.  In  such  case  the  beaks  should  not  be 
driven  against  the  process  with  the  intention  of  breaking  it  down 
in  order  to  secure  an  adjustment,  as  an  aggravated  condition 
will  result.  Where  both  roots  are  left  united,  an  examination 
should  be  made  to  learn  whether  the  remaining  part  of  the  tooth 
can  be  more  readily  released  by  dissecting  away  enough  of  the 


INFERIOR  FIRST  AND  SECOND  MOLARS 


245 


alveolar  process  with  a  bur  on  the  Imgual  and  buccal  sides  to 
allow  a  readjustment  of  the  forceps,  or  whether  the  two  roots 
should  be  separated.  If  it  is  decided  to  remove  the  process,  it 
is  usually  good  practice  to  cut  away  a  little  more  of  the  alveolus 
than  is  absolutely  necessary,  so  that  when  the  forceps  are  applied 
the  operator  can  depend  on  their  remaining  firmly  adjusted  for 
the  delivery  of  the  tooth. 

Where  the  fracture  extends  quite  a  distance  below  the  neck  of 
the  tooth  on  either  the  lingual  or  buccal  side,  or  on  both  sides,  or 


Fig.  120. — Method  of  separating  roots.  A,  fracture  of  an  inferior  first  molar  at  tlie 
gingival  border,  botli  roots  remaining  and  firmly  united;  B,  separating  the  roots 
with  an  engine  bur;  C,  the  roots  separated. 

where  the  alveolus  is  difficult  to  remove  and  the  remaining  struc- 
ture is  of  considerable  size,  the  operative  procedure  should  be  to 
separate  the  roots  and  remove  them  with  the  author's  lower  root 
elevator.  The  separation  of  the  two  roots  is  made  at  their  bifur- 
cation with  a  cross-cut  fissure  bur.  Fig.  120,  A,  shows  the  first 
molar  fractured,  with  both  roots  remaining  and  firmly  united. 
To  separate  the  roots,  the  Imrring  is  started  on  the  buccal  side 
(P^ig.  120,  B)  at  the  bifurcation  of  the  two  roots,  and  is  continued 
until  both  roots  are  separated  (Fig.  120,  C).  If  the  two  roots 
are  not  firmly  united,  a  quicker  separation  can  be  accomplished 


246  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

by  placing  the  edge  of  the  mastoid  chisel  (Fig.  41)  against  the 
occluso-bnccal  side  of  the  tooth  at  the  bifurcation  of  the  roots 
and  striking  it  a  sharp  blow  with  a  plugging  mallet. 

Where  a  fracture  of  the  second  molar  occurs  below  the  margin 
of  the  alveolar  process  and  the  roots  are  fused,  separating  the 
roots  is  impracticable.  The  technic  of  operation  in  such  case  is 
to  apply  the  blade  of  the  author's  lower  root  elevator  (Fig.  18), 
or,  if  the  attachment  is  not  too  firm,  the  Cryer  elevator  (Fig.  25), 
to  the  disto  buccal  surface  of  the  remaining  part  of  the  tooth 
(Fig.  121),  and  send  the  blade  as  far  down  as  possible  between 
the  tooth  and  the  alveolar  process,  when  the  lever  force  of  the 
instrument  is  applied.  This  procedure  will  usually  dislodge  the 
tooth  from  its  attachment.     If  the  first  adjustment  of  the  eleva- 


Flg.  121. — Author's  modified  Cryer  elevator  (Fig.  J."))  applied  to  the  di.sto-buccal  surface 
of  a   fractured  inferior  second  molai-,  the  roots  being  fused. 

tor  fails  to  release  the  tooth,  the  blade  is  sent  further  down,  and 
the  turning  of  the  handle  is  then  repeated  until  the  tooth  is 
detached. 

Two  Boots  Sepandc'd. — Where  a  fracture  occurs,  and  the  two 
roots  remain  and  are  separated,  Standard  forceps  No.  6  (Fig.  7) 
should  be  used  to  complete  the  extraction  if  application  can  be 
made  with  them.  If  it  is  impracticable  to  adjust  these  forceps, 
the  author's  lower  root  elevator  (Fig.  18)  should  be  used.  When 
the  alveolar  process  projects  to  such  an  extent  that  the  blade  of 
this  elevator  cannot  be  applied  to  either  root,  a  part  of  the 
process  is  cut  away  from  either  the  mesial  or  distal  side  of  the 
root,  as  the  case  may  indicate,  to  allow  the  blade  of  the  elevator 
to  be  applied.  The  septum  separating  the  two  roots  may  also  be 
removed.    The  tooth  anterior  or  posterior  to  them,  or  the  alveolar 


INFERIOR  FIRST  AND  SECOND  MOLARS  247 

process,  is  used  as  a  fulcrum,  and  the  operative  procedure  is  tlie 
same  as  that  described  for  using  the  author's  lower  root  elevator 
(page  233). 

Single  Boot. — Where  only  one  root  remains  as  the  result  of  a 
fracture,  the  size  of  the  root  and  its  accessil)ility  should  be 
quickly  noted  to  determine  the  instrument  most  suitable  for  its 
removal.  If  the  part  remaining  is  beyond  the  reach  of  the  for- 
ceps or  author's  lower  root  elevator,  the  Cryer  elevator  should 
be  used,  applying  it  to  the  most  available  surface,  and  using  the 
septum  or  alveolus  as  a  fulcrum.  If  the  root  remaining  has  been 
loosened,  it  can  often  be  readily  lifted  from  its  socket  with  an 
ordinary  explorer  introduced  into  the  root  canal. 

Boots  Deepli/  Seated. — Where  one  or  both  roots  remain  as  the 
result  of  a  fracture,  and  the  parts  are  deeply  seated  and  the 
alveolar  process  is  normal,  a  definite  outline  of  the  remaining 
parts  should  be  ol)tained  l)efore  attempting  to  remove  them. 
The  modified  Cryer  elevator  (Fig.  25)  is  usually  used  to  remove 
such  roots,  and,  if  the  alveolus  interferes  with  its  application, 
the  blade  may  be  utilized  to  cut  away  the  process  sufficiently  to 
allow  an  adjustment.  When  operating  on  the  second  molar,  the 
alveolus  to  the  buccal  side  should,  if  possil)le,  be  used  as  a  ful- 
crum, and,  when  operating  on  the  first  molar,  the  septum  should 
be  used.  If  the  blade  of  the  elevator  cannot  penetrate  the  root, 
the  process  is  cut  away  sufficiently  with  a  suitable  Inir  in  the 
right-angle  to  permit  the  use  of  the  elevator.  Where  this  technic 
is  not  practicable,  the  ]iarts  should  be  removed  with  a  bur,  as 
descril)ed  for  inferior  bicuspid  (page  219). 

Wedged  Roots. — Where  the  crown  of  an  inferior  first  or 
second  molar  has  been  lost  for  some  time,  and  the  adjacent  teeth 
have  tipped  and  partially  closed  the  space  it  formerly  occu])ied, 
so  that  the  roots  cannot  pass  through  the  intervening  space,  and 
if  an  examination  reveals  both  roots  to  be  firmly  united  and  of 
considerable  size,  they  should  be  separated  with  a  fissure  bur  as 
described  in  the  case  of  fracture  (page  244).  When  the  sei^ara- 
tion  has  been  accomplished,  the  author's  lower  root  elevator 
should,  if  possible,  be  adjusted.  If  the  space  will  not,  however, 
permit  this  instrument  to  be  adjusted,  the  Cryer  elevator  should 
be  used,  and  the  blade  adjusted  to  the  most  accessible  root,  or  to 
one  that  will  be  the  easier  to  release  witlioiit  disturbing  the  ad- 
jacent tooth.     On  completion  of  its  removal,  the  remaining  root 


248  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

is  released  with  the  same  elevator.  If  the  two  roots  are  not 
firmly  united,  the  elevator  is  applied  between  them  to  break  up 
their  union,  and  they  are  extracted  separately  with  the  same 
instrument.  When  only  one  root  remains  and  the  space  is  nar- 
row, the  Cryer  elevator  should  be  used. 

Carious  Tooth  Isolated. — Where  the  crown  of  the  second  molar 
is  destroyed  by  caries,  overlaid  with  gum  tissue,  and  isolated,  the 
author's  lower  root  elevator  should  be  applied  for  its  extraction, 
and  the  technic  of  operation  is  the  same  as  that  described  for  the 
third  molar  when  in  the  same  condition  (page  282). 

INFERIOR  THIRD  MOLAR. 

The  inferior  third  molar  is  extracted  more  frequently  than  any 
of  the  other  inferior  teeth.  The  position  of  the  tooth  in  the 
mouth  renders  its  cleansing  difficult,  and  the  free  margins  of  the 
gums  often  form  thick  folds  or  flaps  about  it  that  extend  well  up 
on  the  sides  of  the  tooth,  holding  around  its  enamel  surfaces 
any  debris  that  may  be  forced  between  these  folds  and  the  tooth. 
During  the  eruption  of  the  tooth,  after  the  occlusal  surface  has 
effected  an  opening  in  the  soft  tissue,  further  development  may 
be  retarded  for  an  indefinite  period,  thereby  forming  an  excellent 
receptacle  for  the  retention  of  foreign  matter.  These  factors 
cause  the  tooth  to  receive  very  imperfect  prophylactic  care,  even 
in  the  mouths  of  the  most  scrupulous,  and  it  is  thus  subjected  to 
conditions  that  cause  its  early  decay.  Where  the  tooth  has  been 
attacked  by  caries,  an  attempt  to  retain  it  by  filling  is  often  a 
moot  question,  for,  if  the  remainder  of  the  teeth  in  the  arch  are 
in  good  condition,  it  possesses  little  value  as  an  organ  of  masti- 
cation. If  the  lesions  of  its  surface  have  advanced  far  enough 
to  affect  the  pulp,  successful  treatment  of  the  condition  is  an 
uncertainty  owing  to  the  common  difficulty  of  access  to  its  canals, 
to  the  uncertainty  of  reaching  the  ends  of  mnny  of  these  canals 
with  any  instrument  even  after  access  to  them  is  obtained,  and  in 
some  cases  to  the  impossi])ility  of  inserting  a  canal  filling  that 
will  cause  no  irritation  on  account  of  the  large  apical  forauien, 
due  to  the  incom]ilete  calcification  of  its  roots.  If  caries  has  pro- 
gressed far  enough  to  uiake  the  crowning  of  the  tooth  imperative 
if  it  is  to  be  retniued,  such  procedure  is  seldoui  advisable,  unless 
it  is  in  mesial  occlusion,  due  to  the  loss  of  teeth  anterior  to  it,  or 
it  is  to  serve  as  an  abutment  for  a  bridge,  as  the  shape  of  its 


INFERIOR  THIRD  MOLAR 


249 


Fig.  122. — Types  of  inferior  third  molars.  The  first  row  shows  the  buccal,  the  second 
row  the  lingual,  the  third  row  the  mesial,  and  the  fourth  row  the  distal  surface. 
The  fifth  row  shows  incomplete  and  malformed  molar  roots. 


250  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

crown  and  the  relation  of  the  tooth  to  the  surrounding  tissues 
are  such  that  the  fitting  of  any  artificial  crown  with  sufficient 
accuracy  to  prevent  irritation  of  the  tissues  is,  in  a  majority  of 
cases,  almost  an  impossibility.  The  fact  that  the  posterior  teeth 
in  the  superior  arch  are  also  subject  to  early  loss,  which  loss 
leaves  the  tooth  without  an  antagonist,  is  another  factor  that 
often  makes  it  a  useless  organ. 

In  addition  to  the  pathologic  conditions  that  so  frequently 
make  the  extraction  of  this  tooth  necessary,  it  is  more  frequently 
malposed  than  any  of  the  other  teeth,  and  its  malposition  is  fre- 
quently of  such  character  that,  during  ordinary  mastication,  the 
cheek  and  other  parts  of  the  mouth  are  sul)jected  to  severe  trau- 
matic injury  by  its  peculiar  relation  to  them.  The  aggravated 
conditions  caused  by  the  impaction  of  this  tooth  are  so  common 
that  a  separate  chapter  (page  283)  is  devoted  to  the  treatment  of 
these  conditions. 

Figs.  122  and  123  show  various  types  of  inferior  third  molars. 
In  Fig.  122  the  first  row  shows  the  buccal,  the  second  row  the 
lingual,  the  third  row  the  mesial,  and  the  fourth  row  the  distal 
surface  of  these  teeth.  Attention  is  directed  to  the  variation  m 
the  shape  of  the  crown  and  roots,  and  also  to  the  distal  inclina- 
tion of  the  roots.  The  last  row  shows  two  inferior  third  molars 
with  incomplete  development  of  the  roots,  and  the  other  teeth 
in  the  row  with  markedly  divergent  roots.  Fig.  123  shows  vari- 
ous types  of  inferior  third  molars  with  roots  nearly  straight. 

Position  of  Patient  and  Operator. — The  position  of  the  oper- 
ator for  the  removal  of  this  tooth  is  such  an  important  matter 
that  the  success  of  the  operation,  in  a  large  degree,  depends  on 
it,  and  the  operator  should  not  attemi)t  the  extraction  until  he 
has  assumed  the  correct  position.  The  o])erating  chair,  as  ex- 
plained for  the  position  of  the  operator  and  patient  for  operating 
on  the  inferior  teeth  (page  96),  should  be  adjusted  as  low  as 
possible  and  slightly  tilted  on  account  of  the  posterior  location 
of  this  tooth,  to  which  access  is  not  so  easily  obtained  as  to  the 
teeth  anterior  to  it. 

Where  both  the  elevator  and  forceps  are  employed,  the  oper- 
ator has  two  positions  to  assume.  The  application  of  the  ele- 
vator usually  precedes  that  of  the  forceps,  and  the  change  from 
one  position  to  the  other  is  quickly  made.  When  the  elevator  is 
applied,  the  operator  stands  to  the  right  of  the  patient,  and. 


INFERIOR   THIRD  MOLAR 


251 


Fig.  123. — Types  of  inferior  third  molars.  In  the  first  row  the  roots  are  entirely  sep- 
arated, in  the  second  row  the  roots  are  united  at  the  apices,  in  the  third  row  the 
roots  are  united  throughout  the  entire  length,  and  in  the  fourth  row  the  fusion  of 
the  roots  is  complete. 


252 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


when  the  change  to  the  forceps  is  made,  he  steps  on  a  stool 
behind  the  patient. 

When  operating  on  the  left  side  of  the  arch  with  the  modified 
Lecluse  elevator   (Fig.   23),  the  head  of  the  patient  is  about 


Fig.  124. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
the  elevator  to  the  left  side  of  the  arch.  Illustration  shows  the  application  of  the 
author's  modified  Lecluse  elevator  (Fig.  23)  between  the  second  and  third  molars. 

straight  in  the  head-rest.  The  left  arm  of  the  operator  is  placed 
around  the  head  of  the  patient,  with  the  palm  of  the  hand  steady- 
ing the  head.  The  index  finger  is  nsed  to  retract  the  cheek;  the 
second  finger  depresses  the  lower  lip;  the  third  and  fourth  fingers 
are  placed  below  the  jaw  to  support  the  mandible  (Fig.  124). 


INFERIOR  THIRD  MOLAR 


253 


Wlieu  operating  on  the  riglit  side  of  the  arch  with  the  Lecluse 
elevator  (Fig.  21),  the  head  of  the  patient  is  turned  slightly  to 
the  riglit.  The  left  arm  of  the  operator  is  ])la('ed  around  the 
head,  with  the  palm  of  the  hand  steadying  the  head.     The  index 


Fig.  125. — Position  of  the  operator's  hands  and  disposition  of  the  fingers  when  applying 
the  elevator  to  the  right  side  of  the  arch.  Illustration  shows  the  application  of  the 
Lecluse  elevator  (Fig.  21)  between  the  second  and  third  molars  to  remove  the  third 
molar. 

finger  is  directed  toward  the  lingual  side  of  the  tooth  that  is 
to  be  extracted,  but  should  not  come  in  contact  with  the  tongue; 
the  second  finger  depresses  the  lower  lip;  the  third  and  fourth 
fingers  are  placed  below  the  jaw  to  support  the  mandible 
(Fig.  125). 


254  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

After  the  elevator  lias  been  applied  to  either  side  of  the  arch, 
and  the  change  from  elevator  to  forceps  is  to  be  made,  the  oper- 
ator—with the  left  arm,  hand,  and  fingers  remaining  in  their 
respective  positions — steps  upon  the  stool  back  of  the  patient, 
and,  inclining  his  body  forward,  is  in  the  correct  position  to 
apply  the  forceps  to  the  tooth. 

Maximum  Value  of  Elevator. — A  greater  variation  of  form 
and  a  less  established  relation  to  its  surrounding  tissues  are  pre- 
sented in  the  inferior  third  molar  than  in  any  of  the  other  teeth. 
The  roots  vary  from  a  single  fused  root  to  two  well-formed  roots, 
either  or  both  of  which  may  be  bifurcated,  thereby  forming  three 
or  four  distinct  roots,  and,  in  the  relation  of  the  roots  of  this 
tooth  to  the  mandible,  the  variation  is  from  a  slight  mesial  incli- 
nation to  any  angle  of  distal  inclination,  which  irregularities, 
combined  with  the  many  axes  of  its  roots,  subjects  it  to  almost 
unlimited  variations  in  both  form  and  relation. 

In  the  extraction  of  inferior  third  molars,  no  other  instrument 
for  primar}^  application  approaches  the  effectiveness  of  a  cor- 
rectly made  elevator  when  that  instrument  is  properly  applied. 
If  the  tooth  to  which  application  has  been  made  cannot  be  de- 
livered from  the  socket  with  the  elevator,  the  attempted  extrac- 
tion will  furnish  a  more  dependable  diagnosis  of  the  form  of  the 
tooth,  its  relation  to  the  mandible,  and  the  strength  of  its  at- 
tachment than  could  have  been  obtained  bj'  any  other  method  of 
examination,  except  a  radiograph,  and  such  diagnosis  will  have 
been  made  without  injury  to  tooth  or  surrounding  tissues.  The 
elevator  is  employed  in  advance  of  the  forceps  in  almost  every 
case  when  o[)erating  on  this  tooth,  and  so  much  depends  on  the 
proper  use  of  this  instrument  that  the  operator  should  thor- 
oughly familiarize  himself  with  its  use,  so  that  its  application 
may  be  as  effective  as  possible. 

The  elevator  selected  should  be  of  such  design  that  it  will 
materially  assist  in  the  dislodgment  of  the  tooth  with  the  least 
possible  destruction  of  the  tissues  and  without  causing  fracture. 
The  Lecluse  elevator  (Fig.  21)  and  the  modified  Lecluse  eleva- 
tor (Fig.  23),  the  shank  of  the  latter  being  one  and  one-half 
inches  longer  than  the  former,  are  most  frequently  brought  into 
service.  In  addition  to  these  the  author's  lower  root  elevators 
(Figs.  18,  20)  are  used  where  the  roots  are  to  be  removed,  or 
where  the  tooth  is  in  malalignment  or  isolated,  and  both  the 


INFERIOR   THIRD  MOLAR  255 

regular  and  modified  Cryer  elevators   (Figs.  24,  25)   are  used 
where  fractured  or  deep-seated  roots  are  to  be  extracted. 

An  objection  sometimes  advanced  against  the  use  of  an  ele- 
vator on  this  tooth  is  that  it  may  fracture  the  enamel  on  the 
distal  surface  of  tlie  second  molar  when  that  tooth  is  used  as  a 
fulcrum  to  support  the  instrument.     Such  an  accident  occurs, 
however,   only   in   rare  instances,   and   can   be  avoided  if  the 
operator  uses  good  judgment  in  the  application  of  the  elevator. 
Forceps. — The  forceps  to  be  selected  for  this  tooth  are  the 
same  as  those  used  for  operating  on  the  inferior  first  and  second 
molars  (page  222).    Some  operators  use  for  the  extraction  of  this 
tooth  an  instrument  known  as  Physick  forceps.     The  use  of  these 
forceps  is  not  recommended,  but,  as  there  are  advocates  of  their 
use,  reference  may  be  made  to  them  with  propriety.     Their  use 
is  limited  to  this  tooth,  and  the  author's  experience  has  led  him 
to  discard  them,  as  a  surer,  safer,  and  more  effective  operation 
can  be  performed  with  the  Lecluse  elevator.    When  applying  the 
Physick  forceps,  two  blades  must  be  contended  with,  and  the 
parts  subjected  to  operation  are  so  obscured  by  the  size  of  the 
instrument  that  the  effect  of  the  force  of  application  cannot  be 
observed,  thereby  courting  serious  damage  when  using  them, 
while  the  Lecluse  elevator  has  only  one  blade  and  the  parts 
being  operated  on  can  be  observed  throughout  the  operation. 
Where  resistance  is  encountered,  repeated  application  with  the 
blades  of  the  Physick  forceps  cannot  be  so  well  made  as  with  the 
blades  of  the  Lecluse  elevator.     Where  there  is  an  impingement 
of  the  crown  of  the  third  molar  on  that  of  the  second  molar,  the 
blade  of  the  Physick  forceps  cannot  be  successfully  applied,  and 
in  such  case  often  the  blade  of  the  Lecluse  elevator  can  be  readily 
inserted  into  the  interproximal  space.    In  addition  to  this,  where 
temporary  ankylosis  is  present  and  the  mouth  cannot  be  opened 
very  far,  the  Lecluse  elevator,  being  a  smaller  instrument,  is 
applied  from  the  buccal  side,  whereas  in  using  the  Physick  for- 
ceps the  mouth  must  be  opened  far  enough  to  admit  this  large 
instrument.     It  is  therefore  advisable  for  the  operator  to  famil- 
iarize himself  with  an  instrument  that  is  susceptible  of  more 
general  application  and  whose  use  is  more  effective  and  far  more 
safe. 

Order  of  Extraction. — Where  conditions  permit,  the  extrac- 
tion of  the  third  molar  should  precede  that  of  all  other  inferior 


256  extractions;  technic  of  inferior  teeth 

teeth,  and  especially  that  of  the  second  molar,  which  in  the 
majority  of  cases  may  be  used  as  the  fulcrum  to  support  the  ele- 
vator when  extracting  the  third  molar.  AVhen  both  third  molars 
are  to  be  extracted,  the  one  on  the  left  side  of  the  arch  should  be 
extracted  first. 

Fulcrum. — Where  the  elevator  is  to  be  used  in  the  loosening  or 
removal  of  an  inferior  third  molar,  the  selection  of  the  fulcrum 
is  of  first  importance.  In  the  majority  of  cases  where  the  second 
molar  is  in  situ,  it  serves  as  a  fulcrum,  and  a  definite  knowledge 
of  its  condition  should  be  obtained  before  operating.  Where 
the  second  molar  cannot  be  used  as  a  fulcrum,  or  where  it  is 
missing,  or  where  the  third  molar  is  displaced  to  the  buccal  side 
of  the  arch,  the  alveolar  process  may  often  be  utilized  as  a  suit- 
able fulcrum. 

When  the  Second  Molar  May  be  Used  as  Fulcrum. — Where 
this  tooth  is  in  alignment  with  the  arch,  and  the  teeth  anterior 
to  it  are  in  situ,  the  second  molar  will  be  an  ideal  fulcrum  if  it  is 
firmly  supported  by  the  tissues,  is  free  from  caries  or  filling  on 
its  distal  surface,  or  is  not  crowned.  Where  the  second  molar  is 
not  firmly  attached,  too  much  reliance  should  not  l)e  placed  on  it 
for  a  fulcrum,  unless  it  can  be  effectively  supported,  in  which 
case  it  may  be  used  for  this  purpose.  A  second  molar  unsup- 
ported by  a  tooth  anterior  to  it  should  not  be  depended  on  as  a 
fulcrum  unless  it  can  be  supported,  in  which  case  it  can  often  be 
made  an  ideal  fulcrum.  Fillings  in  the  second  molar  on  any  of 
its  surfaces,  except  the  distal,  unless  they  are  of  considerable 
size,  will  not  prevent  the  use  of  the  tooth  as  a  fulcrum;  and,  even 
with  small  fillings  on  its  distal  surface,  the  tooth  may  be  used  as 
a  fulcrum  if  the  elevator  is  so  applied  that  it  will  not  come  in 
contact  with  the  filling  or  margins  of  the  tooth  about  the  filling. 
Where  the  second  molar  is  supporting  a  well-fitted  shell  crown 
and  the  third  molar  is  not  firmly  attached,  the  second  molar  may 
also  be  used  as  a  fulcrum. 

When  the  Second  Molar  May  Not  be  Used  as  Fulcrum. — Where 
the  second  molar  is  attacked  by  caries,  the  location  and  size  of 
the  cavity  should  be  considered  in  connection  with  the  possibility 
of  this  tooth  being  used  as  a  fulcrum.  If  the  mesial,  occlusal,  or 
buccal  surface  is  involved,  but  not  extensively,  and  the  tooth  is 
firmly  attached  to  the  tissues,  it  may  be  used  as  a  fulcrum.  If, 
however,  caries  is  extensive  on  the  distal  surface,  involving  the 


INFERIOR  THIRD  MOLAR  257 

neck  of  the  tooth,  it  should  not  be  used  for  this  purpose.  Large 
fillings  on  the  distal  surface  of  the  second  molar,  smaller  fillings 
when  projecting  beyond  the  enamel  margins,  and  imperfectly 
fitting  crowns  also  prevent  it  from  being  utilized  as  a  fulcrum. 

Where  the  second  molar  is  supported  by  a  tooth  anterior  to  it, 
but  it  is  not  firmly  attached  to  the  tissues,  it  must  not  be  de- 
pended on  for  a  fulcrum  unless  it  can  be  supported  by  artificial 
means.  If  the  second  molar  is  serving  as  an  abutment  for  a 
bridge,  and  the  span  of  the  bridge  it  supports  is  composed  in 
jDart  of  porcelain,  it  must  not  be  used  as  a  fulcrum;  but,  if  the 
bridge  is  an  all-metal  one,  a  cautious  use  of  the  second  molar 
as  a  fulcrum  is  permissible. 

Methods  of  Reinforcing  the  Fulcrum. — In  some  cases,  where 
a  movement  of  the  second  molar  is  noticed  while  it  is  being  used 


Fig-.  126. — A  decayed  third  molar  to  be  removed  with  the  elevator.  The  second  molar 
is  in  normal  position,  but  the  teeth  anterior  to  it  are  missing.  If  in  such  case  the 
second  molar  is  used  as  a  fulcrum  without  being  reinforced,  the  tooth  will  in  all 
probability  be  loosened  if  considerable  force  is  applied  to  it. 

as  a  fulcrum,  the  tooth  may  be  quickly  reinforced  by  placing 
the  thumb  of  the  left  hand  on  its  occlusal  surface  (Fig.  130)  and 
exerting  a  pressure  downward,  which  will  enable  the  operator  to 
complete  the  extraction  with  little  interruption.  If,  however, 
unsuspected  resistance  is  encountered  in  the  third  molar,  and 
this  means  of  reinforcing  the  second  molar  is  not  sufficient,  its 
use  as  a  fulcrum  should  be  abandoned  rather  than  incur  the  pos- 
sible loss  of  a  useful  tooth.  The  reinforcement  of  the  second 
molar  with  the  thumb  as  described  is  good  technic,  and  is  often 
sufficient  to  allow  this  tooth  to  be  used  as  a  fulcrum  in  a  case 
where  it  would  not  be  practicable  to  employ  it  unsupported. 

Where  the  second  molar  is  well  supported  by  the  tissues,  but 
one  or  more  teeth  anterior  to  it  are  broken  down  by  caries  or 


258 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


have  been  extracted,  any  great  amount  of  leverage  placed  on  the 
second  molar  would  in  all  probability  result  in  the  tooth  being- 
loosened.  To  avoid  such  an  accident,  the  second  molar  may  be 
reinforced  in  a  manner  that  will  render  it  serviceable  as  a  ful- 
crum.    Where  one  or  more  teeth  anterior  to  the  second  molar 


Fig.  127. — A  decayed  third  molar  to  be  removed  with  the  elevator.  Illustration  shows 
the  method  of  reinforcing  the  second  molar  with  a  wood  block  where  the  tooth  is 
to  be  used  as .  a  fulcrum  and  where  the  teeth  anterior  to  the  second  molar  are 
missing. 

are  missing  (Fig.  126),  a  piece  of  wood  may  be  shaped  to  fit  the 
distal  surface  of  the  first  bicuspid  and  the  mesial  surface  of  the 
second  molar  (Fig.  127).  When  pressed  into  position,  it  should 
fit  tightly,  so  that  when  the  elevator  is  applied  the  second  molar 
is  supported  as  though  the  second  bicuspid  and  first  molar  were 
in  their  respective  places. 


A 


Fig  l'>8  —A  decayed  third  molar  to  be  removed  with  the  elevator.  The  mtervenmg 
space  between  the  bicuspid  and  second  molar,  on  account  of  the  mclination  of 
these  two  teeth,  will  not  permit  a  wood  block  to  be  properly  adjusted  to  support 
the  second  molar  when  it  is  to  be  used  as  a  fulcrum. 

It  is  impracticable  to  insert  a  wooden  block  of  this  kind  if  the 
crowns  of  the  adjacent  teeth  are  tipped  respectively  mesially  and 
distally  (Fig.  128).  In  such  case  modeling  compound  should  be 
substituted  for  the  wooden  block.  A  sufficient  quantity  of  the 
compound  is  heated  and  pressed  between  the  deflected  teeth. 


INFERIOR  THIRD  MOLAR 


259 


leaving  a  surplus  of  the  material  projecting  on  the  lingual  and 
buccal  sides,  wliicli  is  forced  into  place  with  the  thumb  and 
index  finger  until  the  mass  is  molded  snugly  into  the  intervening- 
space  (Fig.  129).  After  the  modeling  compound  has  hardened, 
it  possesses  sufficient   rigidity  to    support   the   second  molar. 


Fig.  129. — A  decayed  third  molar  to  be  removed  witli  tlie  elevator.  Illustration  shows 
the  method  of  inserting  modeling  compound  between  the  bicuspids  and  second 
molar  where  a  wood  block  cannot  be  properly  inserted  to  support  the  second  molar 
where  the  latter  tooth  is  to  be  used  as  a   fulcium. 

Where  the  block  or  compound  is  used  in  the  manner  described, 
the  thumb  of  the  left  hand  should,  if  possible,  be  applied  with 
pressure  on  the  supporting  material  during  the  operation  as  an 
additional  means  of  support. 

Impaired  Fulcrum. — Where  the  third  molar  is  not  firmly  at- 
tached to  its  supporting  tissues  and  the  second  molar  is  similarly 


Fig.  1.30. — A  decayed  third  molar  to  be  removed  with  the  elevator.  Illustration  shows 
the  method  of  applying  the  thumb  to  reinforce  the  second  molar  where  it  is  to  be 
used  as  a  fulcrum  and  where  the  teeth  anterior  to  the  second  molar  are  missing. 


impaired,  the  second  molar  may  be  used  as  a  fulcrum  to  extract 
the  third  molar  by  simply  supporting  the  second  molar  with  the 
thumb  of  the  left  hand;  or,  if  the  second  molar  is  not  supported 
by  a  tooth  anterior  to  it,  but  is  firmly  attached  to  the  tissues  and 
the  third  molar  is  not  firmly  attached,  it  may  be  used  as  a  ful- 


260  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

crum  by  supporting  it  in  the  same  manner  with  the  left  thumb 
(Fig.  130).  In  either  case  any  movement  of  the  fulcrum  must 
be  noted  to  avoid  possible  damage  to  the  second  molar. 

Where  the  third  molar  is  firmly  attached  to  the  supporting- 
structures,  and  the  second  molar  is  not  firmly  attached,  or  it  is 
supporting  a  shell  crown  or  an  inlay,  or  it  has  a  large  filling  on 
the  distal  side,  or  its  distal  side  is  extensively  involved  by  caries, 
any  of  which  conditions  would  not  permit  the  second  molar  to  be 
used  to  support  the  elevator,  this  instrument  may  be  applied 
independent  of  the  second  molar.  In  such  case  the  elevator  is 
applied  to  the  buccal  side  of  the  third  molar  as  described  when 
this  tooth  is  weakened  by  caries  on  the  mesial  side  (page  272). 


Fig.  131. — Extraction  of  a  third  molar  witli  the  ele\ator.  The  .second  molar  is  in  align- 
ment, the  teeth  anterior  to  it  are  present,  and  it  can  be  advantageously  used  as  a 
fulcrum. 

Use  of  the  Lecluse  Elevator — Obtaining  Free  Access. — ^AVhen 
the  mouth  is  fully  opened,  the  muscles  of  the  lips  and  cheeks  are 
stretched  taut,  in  which  condition  it  is  impossible  to  distend  the 
tissues  to  either  side  sufficiently  to  obtain  free  access  to  the  field 
of  operation  when  operating  in  the  posterior  part  of  the  mouth. 
A  less  obstructed  view  is  had  when  the  mouth  is  only  partially 
opened.  To  apply  the  Lecluse  elevator  (Fig.  21),  it  will  be  found 
advisable,  as  when  applying  forceps,  to  sacrifice  a  part  of  the 
distance  that  the  teeth  can  be  separated  in  order  to  obtain  a 
greater  retraction  of  the  cheek  tissues.  The  tooth  should  at  all 
times  during  the  operation  be  kept  in  sight  by  the  operator,  for, 
if  the  tooth  dro^DS  on  the  tongue  and  is  not  caught,  it  may  pass 


INFERIOR   THIRD  MOLAR  261 

down  the  throat.  During  the  operation  touching  the  tongue  in 
the  region  of  the  third  molar  should  be  avoided,  as  it  will  gag 
some  patients,  and  may  cause  an  interruption  of  the  operative 
procedure  at  a  critical  time  and  delay  the  completion  of  the 
extraction. 

Operathifi  ou  the  Bight  Side  of  the  Arch. — The  Lecluse  eleva- 
tor (Fig.  21)  is  applied  to  the  inferior  right  third  molar  when  it 
is  in  alignment  (Fig,  131),  and  the  second  molar  is  being  used 
as  a  fulcrum,  by  holding  the  elevator  firmly  in  the  right  hand, 
when  it  is  directed  from  the  Iniccal  side  of  the  arch  into  the  inter- 


Fig.  132. — Same  subject  as  Fig-.  131.  Illustration  shows  the  application  of  the  Lecluse 
elevator  (Fig.  21)  into  the  interproximal  space  between  the  second  and  third  molar 
from  the  buccal  side. 

proximal  space  between  the  second  and  third  molar.  The  flat 
side  of  the  elevator  is  turned  toward  the  mesial  surface  of  the 
third  molar,  while  the  convex  side  engages  the  distal  surface  of 
the  second  molar.  "With  the  elevator  in  this  position  (Fig.  132) 
the  blade  is  forced  between  these  two  teeth.  As  the  l)lade  from 
its  point  to  the  shank  of  the  instrument  is  shaped  in  the  form  of 
a  wedge,  this  pressure  will  often  be  sufficient  to  effect  a  complete 
delivery  of  the  tooth  from  the  socket,  and  it  is  advisable  to  be 
prepared  to  catch  the  tooth  if  it  is  extracted  at  this  juncture.  If 
this  application  fails  to  loosen  the  tooth,  the  extraction  move- 


262 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


ments  are  then  made  as  described  for  the  use  of  this  instrument 
(page  263). 

Operating  on  the  Left  Side  of  the  Arch. — When  removing  the 
inferior  left  third  molar,  the  application  of  the  instrument  and 
use  of  fulcrum  are  the  same  as  described  for  the  right  side 
of  the  arch,  but  the  modified  Lecluse  elevator  (Fig.  23)  should 
be  used  where  the  teeth  are  in  normal  alignment  and  the  attach- 


Fig.  133. — Application  of  the  author's  modified  Lecluse  elevator  (Fig.  23)  between  the 
second  and  third  molar  on  the  left  side  of  the  arch  from  a  position  of  the  operator 
on  the  right  side  of  the  patient. 


ment  of  the  tooth  to  be  removed  is  not  unusually  firm.  The 
elevator  is  held  firmly  in  the  right  hand,  and  is  inserted  into  the 
interproximal  space  on  the  lingual  side  in  the  same  manner  as 
the  regular  Lecluse  elevator  (Fig.  21)  is  introduced  into  the 
interproximal  space  when  operating  on  the  right  third  molar. 
With  the  elevator  thus  applied  (Fig.  133),  it  is  wedged  between 
the  teeth  in  the  same  manner  as  is  done  with  the  Lecluse  elevator 
when  it  is  used  on  the  right  side  of  the  arch.     The  author  recom- 


INFERIOR  THIRD  MOLAR  263 

mends  this  method  of  applying  the  elevator  from  the  right  side 
because  it  avoids  the  necessity  of  the  operator  changing  his  posi- 
tion to  the  left  side  of  the  patient,  and,  not  being  required  to 
change  from  the  right  side,  he  is  enabled  to  quickly  assume  the 
position  for  using  the  forceps  if  they  are  found  necessary  to  com- 
plete the  operation. 

Where  the  inferior  left  third  molar  is  attacked  by  caries  on 
the  mesio-lingual  surface  and  the  mesio-buccal  surface  is  the 
stronger,  or  where  considerable  resistance  or  difficulty  is  en- 
countered, or  where  temporary  ankylosis  is  present,  it  will  be 
necessary  to  operate  with  the  regular  Lecluse  elevator  from  the 
left  side  of  the  patient. 

If,  in  removing  an  inferior  right  third  molar  so  displaced 
buccally  as  to  prevent  the  use  of  the  second  molar  as  a  fulcrum, 
the  elevator  being  introduced  from  the  buccal  side,  the  second 
molar  can  often  be  made  available  as  a  fulcrum  by  introducing 
the  modified  Lecluse  elevator  from  the  lingual  side  while  stand- 
ing on  the  left  side  of  the  patient,  in  the  same  manner  as  de- 
scribed above  for  the  use  of  this  elevator  on  the  inferior  left 
third  molar  in  normal  position. 

Extraction  Movements. — If  the  application  of  the  Lecluse  ele- 
vator as  shown  in  Fig.  132  does  not  loosen  the  tooth,  the  first 
extraction  movement  is  to  direct  the  top  of  the  blade  of  the 
elevator  distally  (Fig.  134),  which  is  done  by  turning  the  upper 
end  of  the  handle  in  that  direction,  and,  if  abnormal  resistance 
is  not  encountered,  the  tooth  will,  as  a  rule,  be  partially  or 
entirely  raised  from  the  socket  by  the  simple  turning  of  the 
instrument.  If,  however,  this  movement  fails  to  loosen  the 
tooth,  the  movement  is  reversed  and  the  lower  edge  of  the  blade 
of  the  elevator  is  directed  distally  (Fig.  135).  If  resistance  is 
still  encountered,  these  movements  are  repeated,  and  the  blade 
is  sent  more  gingivally  and  further  between  the  teeth  with  each 
succeeding  turn  of  the  handle.  The  first  movement — the  top  of 
the  blade  directed  distally — is  favored,  as  the  roots  of  a  majority 
of  inferior  third  molars  incline  distally,  and  this  movement  is 
the  most  effective  in  these  cases.  If  the  elevator  does  not  en- 
tirely liberate  the  tooth  from  the  socket,  the  forceps  should  be 
used  to  complete  the  extraction.  The  distance  that  the  third 
molar  may  be  forced  distally  will  depend  on  the  curvature  and 
amount  of  distal  inclination  of  its  roots,  and  the  resistance  en- 


264  EXTRACTION  TECHNIG  OF  INFERIOR  TEETH 

countered  during  the  extraction  movements.  The  operator's 
sense  of  touch  should  enable  him  to  quite  accurately  determine 
the  curvature  and  inclination  of  the  roots. 

When  using  the  Lecluse  elevator,  one  side  of  the  blade  being 
flat  and  the  other  convex,  turning  the  instrument  transmits  the 
force  by  means  of  an  inclined  plane.  The  flat  side  of  the  blade 
being  toward  the  tooth  to  be  extracted,  turning  the  instrument 
moves  the  incline  over  the  side  of  the  fulcrum  and  directs  the 
force  against  the  opposing  object,  thus  separating  one  from  the 
other.     The  greater  the  curvature  and  distal  inclination  of  the 


Fig.  134. — Same  subject  as  Figs.  131,  13:.'.  Illustration  shows  the  fiist  extraction  move- 
ment with  the  Lecluse  elevator  (Fig.  21)  to  remove  an  inferior  third  molar,  the 
tooth  being  directed  distally  by  turning  the  upper  part  of  the  blade  of  the  elevator 
in  tliat  direction. 

roots  of  an  inferior  third  molar,  the  more  favorable  the  tooth  is 
to  the  ai^plication  of  the  Lecluse  elevator  and  the  less  favorable 
it  is  to  the  application  of  the  forceps.  Where  the  curvature  and 
distal  inclination  of  the  roots  are  extensive,  which  is  the  most 
common  condition  of  this  tooth,  the  effect  of  the  force  thus 
applied  is  much  the  same  as  wlien  a  pinch-bar  is  used  under  a 
wheel  to  cause  it  to  revolve.  The  curvature  and  distal  inclina- 
tion of  the  roots  make  the  axis  of  the  tooth  describe  a  part  of 
the  circumference  of  a  circle,  and  the  force  transmitted  by  the 
elevator  turns  the  tooth  out  of  its  socket. 


INFERIOR  THIRD  MOLAR 


265 


Where  the  crown  of  the  third  molar  is  of  a  small  size,  the 
Lecliise  elevator  should  necessarily  be  used  preceding  the  appli- 
cation of  the  forceps,  as  even  this  tooth  may  have  roots  distally 
inclined  and  of  considerable  size,  and  care  should  be  taken  to 
avoid  fracturing  them. 

Where  the  soft  tissue  overlies  the  disto-occlusal  surface  of  the 
third  molar,  care  should  be  taken  not  to  force  the  tooth  too  far 
distally  during  the  extraction  movements  with  the  Lecluse 
elevator,   as   forcing  the  tooth  too  far  in  that   direction  will 


Fig.  135.— Same  subject  as  Figs.  131,  13:i,  134.  Illustration  shows  the  second  extraction 
movement  with  the  Lecluse  elevator  (Fig.  21)  to  remove  an  mfenor  thn-d  molar, 
the  tooth  being  lifted  from  its  socket  by  turning  the  lower  edge  of  the  blade  ot  the 
elevator  distally  and  engaging  the  tooth  at  its  neck. 

make  the  subsequent  application  of  the  forceps  more  difficult  if 
it  is  necessary  to  apply  them  to  complete  the  extraction.  Where 
it  is  found  that  the  alveolus  posterior  to  the  tooth  has  been  weak- 
ened by  marginal  caries,  special  precaution  should  be  taken  to 
avoid  this  occurrence.  Where  this  tooth  has  been  forced  too  far 
distally,  the  elevator  is  released  from  its  adjustment  on  the 
mesial  surface  and  applied  to  the  distal  surface,  and  the  tooth 
is  pressed  mesially  to  a  position  where  the  forceps  can  be  ap- 
plied.    If  pressing  the  tooth  mesially  in  this  manner  cannot  be 


266  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

done  with  the  elevator,  it  may  be  accomplished  with  a  hook- 
shaped  scaler,  applying  it  to  the  distal  surface  of  the  tooth  and 
pulling  it  forward. 

Where,  during  the  extraction  movements  with  the  Lecluse  ele- 
vator, such  resistance  is  encountered  that  the  tooth  cannot  be 
loosened,  the  operator  will  be  justified  in  concluding  that  the 
roots  are  not  distally  inclined,  when  the  procedure  will  be  to  dis- 
engage the  Lecluse  elevator  and  apply  Standard  forceps  No.  7. 

Application  of  Forceps. — An  application  of  the  forceps  is 
seldom  made  to  an  inferior  third  molar,  when  firmly  attached  to 
the  tissues,  until  after  it  has  been  loosened  with  the  elevator. 
Only  in  those  cases  where  the  roots  are  not  distally  inclined,  or 
where  the  tooth  is  very  loose  and  little  resistance  will  be  encoun- 
tered, should  the  forceps  be  applied  without  the  previous  appli- 
cation of  the  elevator.  As  the  roots  of  this  tooth  are  usually 
curved  and  inclined  distally,  the  application  of  the  forceps  where 
these  conditions  prevail  without  first  loosening  the  tooth  with  an 
elevator  is  not  good  practice,  as  it  is  difficult  in  a  majority  of 
cases  to  execute  any  extraction  movement  with  the  forceps  that 
will  apply  any  great  amount  of  force  disto-occlusally  or  in  the 
line  of  the  tooth's  least  resistance,  while  force  in  this  direction 
is  readily  transmitted  with  the  elevator.  Force  applied  in  any 
other  direction  than  in  line  with  a  continuation  of  the  curvature 
of  the  roots  must  necessarily  be  more  or  less  exerted  transversely 
to  their  long  axes,  and,  when  thus  applied  with  greater  stress 
than  the  roots  will  withstand  in  a  transverse  direction,  they  will 
fracture  unless  the  tissues  surrounding  them  are  weaker  than 
the  roots. 

The  extreme  posterior  location  of  the  tooth,  and  in  addition  the 
gum  tissue,  cheek,  and  tongue,  require  that  the  application  of 
the  beaks  of  the  forceps  should  be  carefully  and  accurately  made. 
As  in  the  case  of  the  first  and  second  molars,  one  beak  is  first 
applied  to  the  lingual  surface  of  the  tooth,  followed  by  the  appli- 
cation of  the  opposing  beak  to  the  buccal  surface,  care  being 
taken  not  to  seize  any  of  the  soft  tissue  in  the  beaks. 

Alveolar  Application  of  Forceps. — An  alveolar  application 
with  the  forceps  should  never  be  attempted  when  the  alveolar 
process  surrounding  the  tooth  is  normal.  The  buccal  ridge  is 
very  heavy  on  that  side  of  the  tooth,  and  will  not  allow  the  beaks 
of  the  forceps  to  penetrate  it.     On  the  lingual  side  the  process  is 


INFERIOR  THIRD  MOLAR  267 

somewhat  lighter,  and  will  allow  an  application  of  this  kind  to 
be  made.  Some  operators  advocate  an  alveolar  application  on 
the  lingual  side  when  considerable  resistance  is  encountered,  the 
beaks  of  the  forceps  being  sent  well  down  on  the  lingual  plate, 
and  the  extraction  movement  is  made  forcibly  toward  the  lingual 
side,  taking  with  it  a  part  of  the  process.  This  is  not  a  good 
procedure  to  follow,  and  in  most  cases  results  in  a  fracture  of 
the  tooth,  with  considerable  destruction  of  the  alveolus,  which 
should  be  avoided.  If  the  forceps  are  to  be  used,  a  safer  opera- 
tion is  to  dissect  away  any  of  the  alveolar  process  that  may  inter- 
fere with  the  application  of  the  beaks  of  the  forceps. 

Extraction  Movements. — After  the  tooth  has  been  partially 
loosened  with  the  elevator,  and  an  adjustment  has  been  secured 
with  Standard  forceps  No.  7,  the  first  extraction  movement  is  to 
bring  the  tooth  slightly  to  the  lingual  side,  after  which  it  is 
directed  posteriorly,  if  possible,  as  far  as  the  curvature  and 
distal  inclination  of  the  roots  demand,  and  then  upward  out  of 
the  socket.  If  any  resistance  is  experienced  while  the  tooth  is 
being  carried  out  of  its  socket  with  the  forceps,  the  operator's 
acute  sense  of  touch  should  indicate  to  him  the  direction  of  least 
resistance.  While  the  least  resistance  is  usually  disto-lingually, 
it  is  not  always  the  case,  and  the  force  of  the  tractile  movement 
should  be  in  the  direction  that  offers  the  least  resistance.  Cau- 
tion should  be  exercised  not  to  cause  a  fracture  of  the  roots  of 
this  tooth  during  the  tractile  movement  by  applying  too  much 
force  in  any  direction,  as  they  are  frequently  of  small  diameter, 
especially  in  the  apical  third,  and  may  curve  in  any  direction. 

Where  the  application  of  the  Lecluse  elevator  has  revealed  the 
fact  that  the  roots  of  an  inferior  third  molar  are  not  distally  in- 
clined, and  Standard  forceps  No.  7  have  been  ai^plied  to  extract 
the  tooth,  they  are  sent  down  on  the  tooth  witli  a  firm,  heavy 
pressure,  and  the  tooth  is  carried  slightly  lingually.  If  the  roots 
are  straight,  this  movement  should  loosen  the  tooth  from  its  at- 
tachment, when  the  extraction  is  completed  by  the  tractile  move- 
ment upward  and  in  the  direction  that  offers  least  resistance. 
If,  however,  the  tooth  is  not  loosened  or  sligliily  i-aised  out  of 
its  socket  by  this  movement,  the  beaks  of  the  forcei^s  are  sent 
further  down  on  the  tooth,  and  the  movement  reiieated  until  the 
tooth  is  sufficiently  detached  to  be  delivered  from  its  socket. 

Occasionally  the  operator  will  be  confronted  willi  a  peculiar 


268  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

condition  after  tlie  tooth  has  been  loosened  with  the  Lechise  ele- 
vator and  has  been  partially  raised  from  its  socket.  When  the 
beaks  of  the  forceps  have  been  secnrely  adjusted  to  the  tooth,  it 
may  be  impossible  to  execnte  any  extraction  movement  to  deliver 
it  from  its  socket.  The  tooth  has  a  tendency  to  move  back  to  its 
orig-inal  position,  and  usually  does  return  to  that  position  if  the 
roots  are  fused,  curved,  and  inclined  distally  to  a  marked  extent. 
In  such  case  a  forcible  extraction  with  the  forceps  should  not  be 
attempted,  as  it  would  cause  the  tooth  or  lingual  plate  to  frac- 
ture. The  tooth  should  be  released  and  the  Lecluse  elevator  re- 
applied, and  the  extraction  movement  made  by  turning  the 
upper  edge  of  the  blade  of  this  instrument  distally,  so  as  to  dis- 
lodge the  tooth  in  that  direction.  This  movement  is  repeated  if 
necessary,  sending  the  blade  further  down  on  the  tooth  with  each 
succeeding  turn,  until  the  tooth  is  entirely  liberated  from  the 
socket.  This  method  of  operating  when  this  condition  is  pre- 
sented is  a  far  safer  procedure  than  an  attempted  forcible  extrac- 
tion with  the  forceps. 

The  condition  described  above  must  not  be  mistaken  for  one 
occasionally  joresented  in  which  one  or  both  of  the  roots  form 
a  curvature  and  then  converge  so  as  to  closely  approximate  or 
be  entirely  united  at  their  termini,  and  the  septum  is  inclosed  in 
the  eyelet  thus  formed.  In  such  case  there  is  not  the  same  ten- 
dency for  the  tooth  to  return  to  its  original  position  after  it  has 
been  loosened  and  the  forceps  have  been  applied  as  in  the  former 
instance,  and,  when  this  condition  is  encountered,  the  extraction 
is  completed  with  the  forceps,  combining  a  short,  swaying  move- 
ment in  the  direction  of  least  resistance,  which  is  usually  disto- 
lingually,  with  a  forcible  but  firm  tractile  movement.  When  the 
tooth  has  been  lifted  a  short  distance  from  its  socket,  the  forceps 
are  reapplied  as  far  down  as  possible,  and  the  extraction  move- 
ments and  reapplications  are  repeated  until  its  delivery  is  com- 
pleted. 

In  the  extraction  of  an  inferior  third  molar,  no  attempt  should 
be  made  to  force  the  tooth  buccally,  as  is  done  with  the  first  and 
second  molars,  as  the  bony  structure  on  the  buccal  side  of  the 
third  molar  is  too  rigid  to  permit  a  successful  movement  in  this 
direction. 

Displacement — 'Complete  LinguaJ. — Where  this  tooth  is  com- 
pletely displaced  to  the  lingual  side  of  the  arch,  a  condition  that 


INFERIOR  THIRD  MOLAR 


269 


is  less  frequent  with  this  tooth  than  a  complete  buccal  displace- 
ment, the  operation  for  its  removal  should  be  carefully  executed 
lo  avoid  injury  to  the  tongue  and  othei"  soft  tissues  that  closely 
approximate  it  on  the  lingual  side.  Fig.  136  shows  a  dry  speci- 
men of  a  complete  lingual  displacement,  with  the  alveolus  par- 
tially overlying  tlie  occlusal  surface  of  the  tooth.  The  removal 
of  the  alveolus  in  advance  of  the  application  of  any  instrument 
for  the  extraction  of  the  tooth  is  the  correct  procedure,  as  the 


Fig.  136. — An  inferior  third  molar  completely  displaced  to  the  lingual  side  of  the  arch, 
witli   the  alveolar  process  partially  covering-  the  occlusal  surface. 


alveolus  interferes  with  the  releasing  of  the  tooth.  When  the 
process  has  been  removed  with  a  bur,  or  if  the  case  is  one  of  com- 
plete eruption  and  this  preliminary  procedure  is  not  necessary, 
the  modified  Lecluse  elevator  is  applied  to  the  mesial  surface  of 
the  third  molar,  the  second  molar  or  the  alveolus  is  engaged  as  a 
fulcrum,  and  the  blade  is  turned  so  as  to  force  the  tooth  slightly 
distally.  At  this  juncture  the  forceps  are  applied,  and,  as  it  is 
impossible  to  use  Standard  forceps  No.  7,  Standard  forceps  No.  4 
or  No.  2  are  selected.     For  the  application  of  either  of  these  for- 


270  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

ceps  the  operator  assumes  a  position  at  the  side  of  the  patient 
oj^posite  to  the  one  where  the  tooth  is  located,  as  when  operating 
on  a  bicuspid  similarly  dispUiced.  When  the  forceps  have  been 
applied,  the  extraction  movement  should  be  made  with  a  pres- 
sure slightly  lingually  and  then  distally,  rej^eating  these  move- 
ments, if  necessary,  until  the  tooth  has  been  sufficiently  loosened 
to  be  delivered  from  its  socket. 

Complete  Buccal. — Where  this  tooth  is  completely  displaced 
to  the  buccal  side  of  the  arch,  it  is  impracticable  to  employ  either 
Standard  forceps  No.  7  or  No.  6,  or  to  apply  the  Lecluse  elevator 
for  its  extraction.  Cases  of  this  character  formerly  gave  the 
author  considerable  concern  on  account  of  the  difficulty  of  gain- 
ing access  and  properl}^  adjusting  an  instrument  whereby  the 
operation  for  the  removal  of  the  tooth  could  be  undertaken  with 
a  reasonable  degree  of  certainty  as  to  results,  but  since  design- 
ing the  elevator  shown  in  Fig.  18  satisfactory  results  are  ob- 
tained with  this  instrument  in  the  oi^eration  for  the  extraction 
of  an  inferior  third  molar  when  so  displaced,  while  the  laceration 
of  the  tissues  and  the  possibility  of  accident  are  reduced  to  a 
minimum.  In  the  use  of  this  instrument  for  the  removal  of  a 
third  molar  in  this  position,  the  first  step  in  the  procedure  is  to 
examine  the  soft  tissue  which  usually  partially  overlies  the 
occlusal  surface,  after  which  the  mesial  surface  is  examined  to 
ascertain  the  practicability  of  applying  the  blade  of  the  elevator 
on  that  side.  As  a  rule,  such  an  application  can  be  made,  but,  in 
case  the  alveolar  process  interferes,  it  is  dissected  away  suffi- 
ciently to  allow  the  application.  It  is  seldom  necessary  to  cut 
away  any  of  the  soft  tissue  previous  to  operating,  as  it  does  not 
materially  interfere  with  the  application  of  the  instrument.  The 
blade  of  the  elevator  is  introduced,  and  presses  away  the  soft 
tissue  from  over  the  occlusal  surface  of  the  crown  in  the  same 
manner  as  is  done  with  the  beaks  of  the  forceps  where  they  are 
applied  to  a  root  that  is  covered  with  gum  tissue.  When  the 
blade  of  the  elevator  has  been  properly  applied  to  the  mesial 
surface  (Fig.  137),  the  necessary  pressure  downward  is  exerted 
— if  necessary,  cutting  through  any  alveolus  that  may  interfere 
— and  the  blade  sent  down  to  a  point  where  a  firm  adjustment  is 
had.  When  such  adjustment  has  been  obtained,  the  upper  end 
of  the  handle  of  the  elevator  is  turned  mesially,  the  alveolar 
process  anterior  to  the  tooth  being  used  as  a  fulcrum,  which  is 


INFERIOR  THIRD  MOLAR  271 

dense  enough  in  this  region  to  bear  the  strain.  This  procedure 
will  loosen  the  tooth  sufficiently  to  allow  the  blade  to  be  sent 
further  down  on  the  tooth,  when  the  handle  is  again  turned 
mesially,  which  will,  as  a  rule,  release  it  from  the  socket.  If, 
however,  the  tooth  is  not  entirely  liberated,  it  will  be  loosened 
and  raised  from  its  socket  to  such  an  extent  that  one  of  the 
Standard  forceps,  the  particular  one  to  be  used  depending  on 
the  condition  presented,  may  be  adjusted  and  the  extraction 
completed,  care  being  taken  in  the  application  of  the  forceps 
not  to  injure  the  cheek. 


X 


Fig.  137. — An  inferior  third  molar  completely  displaced  to  the  buccal  side  of  the  arch. 
Illu.stration  shows  the  application  of  the  author's  lower  root  elevator  No.  1  (Fig.  18) 
to  the  mesial  surface  of  the  tooth. 

Partial  Ling i( a l.—Viheve  the  inferior  right  third  molar  is  par- 
tially displaced  liugually,  the  same  technic  of  applying  the 
Lecluse  elevator  for  its  extraction  is  used  as  that  given  for  the 
tooth  in  alig-nment  (page  263).  Where  the  inferior  left  third 
molar  is  displaced  liugually  in  the  same  manner,  it  is  frequently 
impracticable  to  apply  the  modified  Lecluse  elevator  from  a  posi- 
tion on  the  right  side  of  the  patient,  as  described  (page  262),  and 
in  such  case  the  operator  changes  his  position  to  the  left  of  the 
patient  and  applies  the  Lecluse  elevator  from  that  side  in  the 
usual  manner.  In  other  respects  the  method  of  operating  on  the 
inferior  third  molar  in  partial  lingual  displacement  is  the  same 
as  on  one  in  alignment  with  the  second  molar. 


272  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

Partial  Buccal. — Where  the  inferior  left  third  molar  is  dis- 
placed buccally,  one-third  to  one-half  of  the  crown  being  out  of 
alignment,  the  modified  Lecluse  elevator  is  used  in  the  same 
manner  as  when  the  tooth  is  in  alignment  (page  262).  Where 
the  tooth  is  on  the  right  side,  the  operator  assumes  a  position  to 
the  left  of  the  patient,  and  uses  the  modified  Lecluse  elevator 
from  that  side  in  the  same  manner  as  when  the  tooth  is  in  align- 
ment. If  the  tootli  cannot  be  entirely  removed  with  an  elevator, 
the  forceps  are  applied  to  complete  the  operation,  the  method 
of  their  use  being  the  same  as  is  employed  where  the  tooth  is 
in  normal  position. 

Crown  DistaUy  Inclined .— Where  the  tooth  is  in  alignment, 
but  its  crown  is  directed  distally,  the  operator  should  follow  this 
inclination  in  the  extraction  movements  that  are  to  be  made  with 
the  Lecluse  elevator,  aiming  to  direct  the  tooth  more  distally 
by  continued  reapplicatiou  of  the  instrument.  This  procedure 
will  dislodge  the  tooth  and  prevent  fracture  of  the  roots,  as  in 
such  case  the  roots  are  usually  inclined  in  the  same  direction  as 
the  crown. 

Extensive  C&ries— Bxcca II t/ . — Caries  on  the  buccal  surface  of 
this  tooth  is  common,  and,  when  present,  does  not  as  a  rule 
greatly  complicate  its  extraction.  The  Lecluse  elevator  is  ap- 
plied to  the  mesial  surface  of  the  tooth  as  though  no  caries  exists 
(page  260).  AVhere  caries  is  extensive,  the  operator  should  en- 
deavor to  remove  the  tooth  entirely  from  the  socket  with  the 
Lecluse  elevator,  so  as  to  avoid  the  necessity  of  applying  the 
forceps.  When,  however,  it  becomes  necessary  to  use  the  for- 
ceps, the  buccal  beak  is  first  applied,  care  being  taken  to  place 
it  as  far  down  as  possible  on  that  surface,  and  the  usual  extrac- 
tion movements  are  em])loyed  for  the  removal  of  the  tooth. 

LlnguuUy. — Where  this  tooth  is  attacked  by  caries  on  the 
lingual  surface,  the  beak  of  the  forcei3s  should  not  be  applied  to 
this  surface  until  after  the  tooth  has  been  loosened  with  the 
Lecluse  elevator,  care  being  taken  that  a  firm  grasp  is  obtained 
with  the  forceps  on  the  buccal  surface  also,  as  the  first  extraction 
movement  is  made  forcibly  to  the  lingual  side,  and  it  is  important 
that  the  beak  engaging  the  lingual  side  retains  its  position,  or  a 
fracture  will  usually  result. 

Mesially. — Where  the  seat  of  caries  is  on  the  mesial  surface, 
and  the  mesio-buccal  wall  is  the  stronger,  the  Lecluse  elevator  is 


INFERIOR  THIRD  MOLAR  273 

applied  from  the  buccal  side;  but,  if  the  inesio-lingual  wall  is  the 
stronger,  the  modified  Lecluse  elevator  is  applied  from  the  lin- 
gual side.  In  most  of  these  cases  it  is  advisable  to  secure  an 
adjustment  on  the  neck  or  mesial  root  of  the  tooth,  and  not 
depend  on  the  crown  for  support. 

Where  the  mesial  surface  is  involved  by  caries  to  such  an 
extent  that  it  is  fragile,  and  not  strong  enough  to  support  the 
Lecluse  elevator,  the  instrument  should  be  applied  to  the  buccal 
surface  if  that  wall  remains  intact.  In  making  this  applica- 
tion, the  flat  side  of  the  blade  is  applied  to  the  buccal  side  of  the 
tooth,  and  sufficient  pressure  is  exerted  to  send  the  blade  below 
the  free  margin  of  the  gum  and  down  between  the  marginal  edge 
of  the  alveolus  and  the  tooth,  when  the  handle  of  the  elevator 
is  brought  with  some  force  downward  and  buccally,  the  alveolus, 
which  is  heavy  on  this  side,  serving  as  a  fulcrum.  This  move- 
ment will  direct  the  tooth  disto-lingually  and  raise  it  partially 
out  of  its  socket,  when  the  blade  is  sent  down  into  the  space 
gained  and  the  handle  is  again  directed  downward  and  buccally, 
after  which,  while  retaining  a  secure  application  of  the  instru- 
ment to  the  tooth,  pressure  is  exerted  disto-lingually.  This 
method  of  operating,  if  properly  executed,  should  release  the 
tooth  to  such  an  extent  that  the  forceps  may  be  applied  to  com- 
plete the  extraction. 

Distally. — Where  this  tooth  is  attacked  by  caries  on  the  distal 
surface,  with  a  reasonably  strong  mesial  half  of  the  crown  re- 
maining, the  technic  of  applying  the  Lecluse  elevator  is  the  same 
as  though  no  caries  exists  (page  260).  After  the  tooth  has  been 
loosened  or  partially  brought  out  of  the  socket  with  the  elevator, 
the  forceps  are  carefully  applied,  the  operator  using  Standard 
forceps  No.  7  or  No.  6,  depending  on  the  size  of  the  remaining 
part  of  the  tooth.  Where  the  cavity  is  large  and  the  crown  con- 
siderably weakened,  the  blade  of  the  elevator  is  applied  to  the 
neck  or  even  to  the  mesial  root  of  the  tooth,  as  reliance  should 
not  be  placed  on  the  crown  to  withstand  the  force  necessary  for 
the  extraction. 

Two  Roots  United — Elevator  Indicated. — Where  only  the  roots 
of  this  tooth  remain,  and  they  are  still  united  or  fused  into  one 
root,  are  of  fair  size  and  reasonably  sound,  and  are  firmly  at- 
tached to  the  tissues,  the  Lecluse  elevator  is  employed  for  their 
removal.    When  applying  this  instrument,  the  blade  should  be 


274  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

sent  with  sufficient  jjressure  between  the  second  molar  and  the 
mesial  root  to  carry  it  to  a  point  where  a  good  adjustment  is  had 
on  the  sound  structure  of  the  root  before  the  extraction  move- 
ments are  attempted.  When  the  roots  are  not  entirely  liberated 
by  this  procedure,  Standard  forceps  No.  7  or  No.  6  are  used  to 
complete  the  extraction.  If  the  mesial  root  is  so  fragile  that  the 
blade  of  the  Lecluse  elevator  (Fig.  21)  cannot  be  securely  ad- 
justed to  it,  the  author's  lower  root  elevator  (Fig.  18)  should  be 
used.  The  blade  of  the  latter  instrument  is  sent  into  the  inter- 
proximal space,  and,  if  necessary,  the  blade  cuts  a  short  dis- 
tance into  the  alveolus  in  order  to  gain  a  firm  adjustment.  The 
upper  end  of  the  handle  is  then  turned  mesially,  which  will  cause 
the  point  of  the  blade  to  engage  the  root,  which  movement  will 
usually  release  the  roots.  If  resistance  is  still  encountered,  the 
application  of  the  blade  and  turning  of  the  handle  are  repeated 
until  the  extraction  is  completed.  The  roots  will  usually  leave 
the  socket  together,  but,  if  they  become  separated,  the  mesial 
root  will  be  released.  Where  the  distal  root  remains,  the  blade 
of  the  author's  lower  root  elevator  is  inserted  into  the  socket  of 
the  extracted  mesial  root,  and  the  blade  is  sent  as  far  down  as 
possible  on  the  mesial  surface  of  the  distal  root.  As  the  blade 
of  this  elevator  is  rather  large,  the  second  molar  can  be  utilized 
as  a  fulcrum,  when  the  handle  is  turned  mesially  with  sufficient 
pressure  to  engage  the  distal  root  and  lift  it  from  its  socket. 

Forceps  Indicated. — Where  the  roots  are  united  or  fused,  and 
are  not  firmly  attached  to  the  tissues.  Standard  forceps  No.  7  or 
No.  6  may  be  used  to  extract  them.  This  method  of  procedure 
is  favored  where  the  forceps  can  be  used  successfully  for  their 
extraction,  especially  when  the  same  forceps  are  to  be  used  to 
extract  one  or  more  teeth  anterior  to  this  one  at  the  same  sitting, 
and  the  operator  desires  to  avoid  the  loss  of  time  required  to 
change  instruments.  When  the  beaks  of  the  forceps  are  applied, 
a  firm,  steady  downward  pressure  will  usually  release  the  roots 
on  the  initial  application.  If,  however,  the  roots  are  not  re- 
leased, the  extraction  movements  described  when  the  crown  is 
intact  (page  267)  will  detach  them. 

Two  Roots  Separated — Elevator  Indicated. — Where  only  the 
roots  of  this  tooth  remain  and  are  separated,  are  of  fair  size  and 
accessible,  and  are  firmly  attached  to  the  tissues,  they  are  ex- 
tracted by  the  application  of  the  Lecluse  elevator  to  the  mesial 


INFERIOR   THIRD  MOLAR  275 

root  in  the  same  manner  as  when  the  roots  are  united  (page  273). 
If  the  distal  root  is  in  close  proximity  to  the  mesial  root,  fre- 
quently the  carrying  of  the  latter  root  distally  in  its  extraction 
will  release  the  former.  If  the  distal  root  is  not  released  with 
the  mesial  root,  the  elevator  is  applied  to  the  mesial  surface  of 
the  distal  root  to  dislodge  it,  as  described  (page  263). 

Where  the  mesial  root  is  fragile  on  the  mesial  side,  and  the 
distal  root  is  in  close  proximity  to  that  root,  the  author's  lower 
root  elevator  should  be  adjusted  between  the  two  roots,  and  the 
mesial  root  or  the  septum  used  as  a  fulcrum  to  dislodge  the  distal 
root,  after  which  the  mate  to  the  elevator  is  inserted  into  the 
emjDty  socket,  and  the  blade  is  adjusted  to  the  distal  side  of  the 
mesial  root  for  its  extraction. 

Forceps  Indicated. — Where  only  the  roots  of  this  tooth  remain 
and  are  separated,  are  accessible,  and  are  not  firmly  attached  to 
their  tissues.  Standard  forceps  No.  6  may  be  applied  as  described 
when  the  roots  are  united  (page  274),  applying  the  forceps  first 
to  the  stronger  or  more  accessible  root. 

Single  Root. — Where  only  one  root  of  this  tooth  remains,  and 
it  is  the  mesial  root,  if  of  fair  size  and  firmly  attached,  the  Le- 
cluse  elevator  is  applied  as  described  for  the  extraction  of  the 
mesial  root  when  both  roots  are  separated  (page  273) ;  or,  if  the 
remaining  root,  whether  mesial  or  distal,  is  not  firmly  attached, 
Standard  forceps  No.  6  may  be  employed  for  its  extraction,  pro- 
vided application  to  it  can  be  made  with  them. 

Roots  Covered  by  Gum  Tissue. — If  one  or  both  roots  remain, 
and  the  gum  tissue  covers  them,  the  operator  should  not  attempt 
to  apply  any  instrument  for  their  extraction  until  after  he  has 
learned  the  size  and  position  of  the  roots  and  their  relation  to 
the  tissues.  In  such  case  the  explorer  should  be  introduced 
below  the  soft  tissue,  and,  if  possible,  the  desired  information 
obtained  by  a  careful  examination.  If  it  is  impossible  to  make 
an  accurate  diagnosis  by  explorative  examination,  a  radiograph 
should  be  secured,  especially  where  a  previous  attempt  to  extract 
the  roots  has  been  made.  If  in  such  case  the  application  of  an 
instrument  is  attempted  without  first  procuring  a  radiograph  of 
the  parts,  the  accuracy  of  the  a])plication  will  be  in  doubt,  and  a 
failure  to  extract  the  roots  will  likely  be  the  result,  especially  if 
they  lie  in  a  horizontal  position,  or  if  they  impinge  on  the  distal 
root  of  the  second  molar. 


276  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

Where  the  examination  shows  that  the  roots  are  not  inclined 
from  their  normal  position,  and  a  good  adjustment  can  be  made 
with  the  Lecluse,  author's  lower  root,  or  Cryer  elevator,  tlie 
elevator  most  suited  for  the  particular  case  is  selected,  and  it  is 
applied  by  the  method  indicated  for  operating  on  a  similar  root 
with  the  field  of  operation  exposed,  using  the  lancet  to  sever  the 
parts  only  when  it  is  necessary  to  permit  an  application  of  the 
instrument  or  to  allow  a  free  exit  of  the  root  from  its  socket. 

Where  a  radiograph  shows  that  the  roots  are  not  favorably 
situated,  and  impinge  on  the  distal  root  of  the  second  molar,  or 
are  in  a  horizontal  position,  the  same  technic  of  operation  is  ap- 
])lied  as  when  the  tooth  is  impacted  in  a  similar  position. 

Screw-Porte. — The  screw-porte  cannot  be  used  in  connection 
with  the  extraction  of  this  tooth,  as  it  is  impracticable  to  use  the 
instrument  on  account  of  the  curvature  of  the  roots  and  the 
extreme  posterior  position  of  the  tooth. 

Fracture. — A  fracture  of  this  tooth  in  an  endeavor  to  extract 
it  is  of  quite  common  occurrence,  and  is  sometimes  unavoidable, 
as  its  abnormalities  are  numerous  and  the  pathologic  conditions 
of  the  tooth  and  tissues  are  varied,  and  these  factors,  combined 
with  the  peculiarities  of  mouth  and  individual,  make  an  almost 
unlimited  number  of  difficulties  to  be  overcome  in  its  successful 
extraction  in  all  the  cases  presented. 

Where  a  fracture  of  the  crown  occurs,  the  operator  should 
quickly  determine  whether  he  can  reapply  the  elevator  to  com- 
plete the  extraction,  as  time  and  inconvenience  is  saved  if  this 
can  be  done  and  the  instrument  reapplied  before  the  hemorrhage 
obscures  the  remaining  part  of  the  tooth.  Usually  the  elevator 
can  be  successfully  reapplied  in  such  case,  and  the  extraction 
completed  as  though  the  accident  had  not  occurred.  Where  such 
fracture  occurs,  the  operator  is  often  tempted  to  apply  the  for- 
ceps, but  this  is  not  a  good  procedure,  for,  if  the  forceps  were  not 
indicated  before  the  fracture,  they  are  seldom  indicated  after 
the  fracture.  If  the  hemorrhage  has  obscured  the  parts  and  the 
operator  is  uncertain  as  to  the  condition  of  the  structure  remain- 
ing, the  parts  should  be  freed  of  blood  with  absorbent  cotton  and 
carefully  examined.  If  the  remaining  part  of  the  tooth  is  nor- 
mally situated,  and  there  is  sufficient  structure  to  permit  the 
Lecluse  or  author's  lower  root  elevator  to  be  applied  to  the 
mesial  surface,  such  application  should  be  made.     If,  however, 


INFERIOR  THIRD  MOLAR  277 

the  alveolus  interferes  with  the  application  of  the  elevator  at 
this  point,  a  part  of  it  anterior  to  the  tooth  is  cut  away  with  a 
fissure  bur,  so  that  a  reapplication  of  the  elevator  can  be  made 
to  complete  the  extraction. 

Where  the  fracture  extends  quite  a  distance  down  on  the 
mesial  surface,  and  the  parts  are  firmly  attached,  an  adjustment 
of  the  blade  of  the  elevator  to  that  surface  is  often  impracticable. 
In  such  case  the  operator  should  examine  the  buccal  surface,  and, 
if  it  is  found  firm  and  the  alveolus  does  not  project  beyond  the 
part  remaining  on  the  buccal  side,  the  Lecluse  elevator  should 
be  applied  to  this  surface  and  the  tooth  extracted  by  the  method 
described  when  the  mesial  surface  is  extensively  attacked  by 
caries  (page  272).  If  this  method  of  operating  is  impracticable, 
the  process  should  be  dissected  away,  preferably  on  the  mesio- 
buccal  side,  and  the  Lecluse  or  author's  lower  root  elevator  ad- 
justed to  that  side  to  etfect  the  delivery  of  the  parts  remaining. 

If  the  fracture  involves  the  mesial  and  buccal  sides  to  such  an 
extent  that  an  application  of  the  elevator  cannot  be  made  on 
these  sides,  the  operator  should  examine  the  alveolus  on  the 
lingual  and  distal  sides  for  an  adjustment.  Occasionally  the 
fracture  will  extend  diagonally  across  the  tooth,  the  lingual  or 
distal  wall  remaining  well  above  the  process,  while  mesially  and 
buccally  it  has  extended  for  quite  a  distance  below  the  process. 
When  this  occurs,  the  modified  Cryer  elevator  can  often  be  ap- 
l)lied  to  the  lingual  or  distal  wall  and  enough  leverage  obtained 
to  loosen  the  parts.  All  other  conditions  being  equal,  the  side 
affording  the  better  access,  adjustment,  and  fulcrum  is  selected; 
but,  if  the  roots  are  considerably  curved  and  incline  distally,  the 
distal  application  is  preferred,  while  the  lingual  application  is 
best  suited  for  a  tooth  with  straight  roots  and  little  distal  in- 
clination. In  either  application  the  process  on  the  side  of  the 
application  is  utilized  as  a  fulcrum,  and  the  point  of  the  elevator 
is  forced  between  it  and  the  tooth,  being  turned  so  that  the  point 
of  the  blade  engages  the  root.  If  a  lingual  or  distal  application 
of  the  modified  Cryer  elevator  is  not  ]U'acticable,  the  roots,  if 
fused  into  one,  are  removed  by  cutting  away  tlie  alveolar  process 
before  applying  the  elevator.  If  an  examination  indicates  that 
the  tooth  has  two  roots,  and  they  can  be  separated,  a  division  is 
obtained  by  using  a  bur,  as  described  when  separating  the  roots 
of  the  first  molar  (page  244)  in  which  case  tlie  author's  lower 


278  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

root  elevator  is  adjusted  to  the  mesial  surface  of  the  distal  root, 
using  the  mesial  root  as  a  fulcrum,  and  the  root  is  dislodged 
distally.  When  the  distal  root  has  been  extracted,  the  mate  to 
the  elevator  is  introduced  into  the  empty  socket  and  applied  to 
the  distal  side  of  the  mesial  root,  which  is  then  dislodged  by 
turning  the  upper  end  of  the  handle  distally. 

Where  the  fracture  occurs  below  the  alveolar  process,  but  the 
alveolus  surrounding  the  tooth  has  been  weakened  by  caries,  and 
the  remaining  fractured  part  is  of  considerable  size,  the  author's 
lower  root  elevator  is  applied  to  extract  the  tooth,  as  the  blade 
of  this  instrument  is  sharper  than  that  of  the  Lecluse  elevator, 
and  can  cut  through  any  diseased  alveolus  that  it  may  be  neces- 
sary to  penetrate  in  order  to  obtain  an  adjustment  to  the  frac- 
tured part  of  the  tooth. 

Single  Root  Bemaininfj. — Where  only  one  root  remains  and  it 
is  the  mesial  root,  the  Lecluse  elevator,  if  it  can  be  securely  ad- 
justed, is  applied.  If,  however,  the  mesial  root  is  so  located  that 
the  Lecluse  elevator  cannot  be  applied,  the  author's  lower  root 
elevator  is  introduced  into  the  empty  socket  and  the  blade  en- 
gages the  distal  side,  using  the  alveolus  as  a  fulcrum.  If  the 
distal  root  remains,  the  author's  lower  root  elevator  is  applied 
to  its  mesial  side  by  introducing  the  blade  into  the  socket  of  the 
mesial  root.  Where  the  part  is  not  very  large,  the  modified 
Cryer  elevator  is  favored,  and  is  applied  in  the  same  manner  as 
the  author's  lower  root  elevator.  Where  the  root  is  so  deeply 
seated  that  a  firm  adjustment  cannot  be  obtained  with  the  ele- 
vator, sufficient  alveolus  must  be  cut  away  from  the  root  to  per- 
mit the  adjustment  of  this  instrument  and  allow  the  leverage 
necessary  to  release  the  tooth  from  its  attachment. 

Application  of  the  elevator  to  a  root  must  be  made  in  such 
manner  that  it  may  be  carried  from  its  socket  in  the  direction  of 
its  axis,  and,  as  the  roots  of  an  inferior  third  molar  are  prone 
to  take  a  position  in  the  tissues  at  nearly  any  angle  of  inclina- 
tion, great  care  must  be  exercised  in  their  extraction  and  no 
attempt  should  be  made  to  perform  the  impossible.  To  illustrate 
this  statement,  a  case  is  presented  from  the  j)ractice  of  the 
author,  as  follows: 

After  the  fracture  the  socket  was  cleared  of  blood  with  absorb- 
ent cotton  and  the  root  located.  Examination  of  the  extracted 
tooth  and  the  part  remaining  in  position  showed  that  the  root 


INFERIOR  THIRD  MOLAR  279 

was  markedly  inclined  distally  and  lay  in  an  almost  horizontal 
position.  To  apply  the  blade  of  the  elevator  below  or  to  the  side 
of  the  root  to  release  it  was  not  practicable,  as  the  process  over  it 
would  prevent  its  delivery.  The  root  was  exposed  by  burring 
away  a  small  portion  of  the  alveolus  overlying  it.  The  blade  of 
the  modified  Cryer  elevator  was  applied  in  such  manner  that  its 
sharp  point  penetrated  the  root  from  its  upper  side,  after  which 
the  root  was  brought  mesially  with  some  degree  of  force  in  line 
with  its  inclination  and  carried  out  of  its  socket.  No  attempt 
was  made  to  carry  the  root  upward,  as  this  would  have  been  an 
impossibility. 

Boots  Deeply  Seated. — "Where  small  parts  of  the  apical  ends 
of  the  roots  are  in  situ  and  are  deeply  seated  in  the  tissues  as  the 
result  of  a  fracture,  they  should  be  allowed  to  remain  if  they  are 
not  the  exciting  cause  of  some  pathologic  condition;  but,  if  a 
pathologic  condition  exists,  these  parts  must  be  removed.  The 
socket  should  be  cleared  of  blood,  and  the  soft  tissue  sufficiently 
dilated  to  allow  an  examination  to  be  made  for  the  purpose  of 
locating  the  parts.  When  the  parts  have  been  located,  the 
method  of  operating  should  be  carefully  outlined  in  advance  so 
as  to  remove  them  with  as  little  destruction  as  possible  of  the 
adjacent  tissues,  and  with  as  few  attempts  to  release  them  as 
conditions  will  permit.  The  preferred  method  in  such  case  is  to 
use  the  modified  Cryer  elevator  to  effect  their  delivery.  The 
blade  of  this  elevator  is  forced  between  the  remaining  roots  and 
the  alveolus,  and  the  handle  turned  to  dislodge  them.  If,  how- 
ever, this  instrument  cannot  be  adjusted  so  as  to  engage  the 
roots,  they  should  be  cut  out  with  a  bur,  as  this  method  is  pref- 
erable to  any  other  procedure  that  may  cause  extensive  laceration 
of  the  surrounding  tissues. 

Isolated  Tooth — Orouni  Intact. — Where  this  tooth  is  isolated 
(Fig.  138)  and  extraction  is  indicated,  the  operator  is  warned 
against  the  immediate  application  of  the  forceps  if  the  tooth  is 
firmly  attached  to  its  supporting  tissues,  as  the  alveolar  process 
is,  as  a  rule,  very  dense  around  such  a  tooth,  and  this,  with  the 
usual  distal  inclination  of  the  roots,  would  predispose  the  neck 
or  roots  to  fracture.  The  many  cases  of  failure  in  the  attempted 
extraction  of  such  a  tooth  that  have  come  under  the  observation 
of  the  author  has  led  him  to  conclude  that  it  is  a  common  practice 
in  such  cases  to  apply  the  forceps  without  a  previous  application 


280 


EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 


of  the  elevator.  The  operative  procedure  in  this  case  differs 
from  that  described  where  the  second  molar  can  be  used  as  a 
fulcrum,  as  the  operator  must  depend  on  the  alveolar  process 
anterior  to  it  for  a  fulcrum.  The  author's  lower  root  elevator 
(Fig.  18)  is  the  instrument  indicated  for  preliminary  application. 


Fig-.  13S. — An  isolated  inferior  third  molar. 


The  blade  of  the  elevator  is  applied  to  the  mesial  surface  of  the 
tooth  (Fig.  139),  and  is  sent  between  the  free  margin  of  the  gum 
and  the  tooth  to  the  margin  of  the  alveolar  process.  If  a  good 
adjustment  can  be  obtained  at  this  point,  the  extraction  move- 


Fig.  139.— Same  subject  as  Fig.  138.     Illustration  shows  the  application  of  the  author's 
lower  root  elevator  No.   1  (Fig.  18)  to  the  mesial  surface  of  the  tooth. 

ments  are  immediately  begun.  If,  however,  the  tooth  cannot  be 
properly  engaged  with  the  point  of  the  elevator,  or  the  process 
does  not  serve  as  a  suitable  fulcrum,  the  pressure  on  the  blade  is 
increased  so  as  to  cut  through  the  process  to  provide  a  firm  sup- 
port.    The  extraction  movements  are  then  executed  by  turning 


INFERIOR   THIRD  MOLAR 


281 


Fig.  140. — An  isolated  inferior  tliird  molar,  with   the  crown   destroyed  by  caries. 


Fig.  141. — Same  subject  as  Fig.  140.     Illustration  shows  the  application  of  the  author's 
lower  root  elevator  No.  1  (Fig.  18)  to  the  mesial  surface  of  the  tooth. 


¥\g.  H2, — Samt^   subject   as    Figs.    140,    141.     Illustration   shows    the   tooth   partly   deliv- 
ered from  its  socliet  with  the  elevator. 


282  EXTRACTION  TECHNIC  OF  INFERIOR  TEETH 

the  upper  end  of  the  handle  mesially  with  a  force  varying  with 
the  rigidity  of  the  tooth's  attachment.  This  will  send  the  point 
of  the  blade  into  the  tooth,  and  a  repetition  of  these  movements 
will  raise  the  tooth  ont  of  the  socket  so  that  the  extraction  can 
be  completed  with  the  forcej3s. 

Crown  Destroyed. — AVhere  the  crown  of  an  isolated  third  molar 
has  been  destroyed  by  caries  and  only  the  roots  remain,  the  gum 
tissue  usually  covers  them  partially  or  completely.  The  appli- 
cation of  the  forceps  in  such  case  would  be  extremely  difficult, 
and  could  not  be  made  without  considerable  laceration  of  tissue. 
In  addition,  a  certain  amount  of  guesswork  would  attend  the 
application,  and  probably  several  attempts  would  be  necessary 
before  a  satisfactory  adjustment  could  be  made.  As  the  process 
is  frequently  very  dense  around  such  roots,  and,  unless  this 
process  has  been  weakened  l)y  caries,  it  is  frequently  impossible 
to  secure  an  adjustment  with  the  forceps  that  will  deliver  the 
roots.  In  a  case  of  this  kind  the  result  of  the  operation  will 
be  surer  if  an  elevator  is  used  before  the  application  of  the 
forceps.  Where  the  entire  crown  is  destroyed,  leaving  only  the 
roots  (Fig.  140),  the  author's  lower  root  elevator  is  applied  to 
the  mesial  side  (Fig.  141),  and  the  blade  is  sent  between  the  root 
and  gum  tissue  with  sufficient  force  to  cut  through,  if  necessary, 
enough  of  the  alveolar  process  for  the  point  of  the  instrument  to 
engage  the  root.  When  this  has  been  done,  the  ]3rocess  anterior 
to  the  tooth  is  used  as  a  fulcrum  and  the  top  of  the  handle  of  the 
elevator  is  turned  mesially,  which  will  ]n'ize  the  tooth  from  its 
socket  (Fig.  142).  If  the  extraction  is  not  completed  by  this 
operation,  the  attachment  of  the  tooth  will  have  been  sufficiently 
broken  up  and  the  parts  elevated  from  the  original  position 
enough  to  allow  them  to  be  readily  removed  with  the  forceps. 


CHAPTER  XI. 

EXTRACTION  TECHNIC  OP  IMPACTED  INFERIOR 
THIRD  MOLAR. 

The  inferior  third  mohir  is  impacted  more  frequently  than  any 
other  tooth,  and,  when  extraction  is  indicated,  the  selection  of 
the  correct  operative  technic  necessary  for  its  removal  demands 
good  judgment  and  the  execution  of  the  technic  requires  consid- 
erable skill.  The  removal  of  this  tooth  is  strictly  a  surgical  pro- 
cedure, and  should  be  executed  in  a  manner  not  to  disturb  the 
second  molar  or  to  cause  unnecessary  injury  to  the  associated 
tissues.  Any  pathologic  condition  of  the  surrounding  structures 
that  may  be  associated  with  this  tooth  when  impacted  should  be 
taken  into  consideration  preceding,  during,  and  following  the 
operation. 

To  alleviate  the  pain  caused  by  the  tooth,  and  quite  frequently 
to  avoid  operating  where  an  operation  is  indicated,  the  tissues 
overlying  the  occlusal  surface,  when  in  an  inflammatory  condi- 
tion, are  irrigated  with  antiseptic  solutions,  and  such  medica- 
ments as  iodin,  aconite,  campho-phenique,  or  nitrate  of  silver  are 
applied.  In  case  of  the  first  attack,  temporary  relief  will  usually 
be  obtained  by  this  form  of  treatment,  but,  where  a  number  of 
such  attacks  have  occurred  or  where  suppuration  is  established, 
little  or  no  relief  may  be  expected  from  such  application.  The 
tissues  about  the  tooth  are  severed  with  a  lancet  also  in  an  en- 
deavor to  relieve  the  condition,  but  this  usually  increases  the 
trouble  and  affords  a  favorable  field  for  infection. 

To  postpone  the  removal  of  this  tooth  when  it  is  a  source  of 
irritation  to  the  patient,  and  the  conditions  cannot  be  corrected 
exce]it  by  its  removal,  only  tends  to  complicate  the  o]ierntion  for 
its  ultimate  extraction. 

The  extraction  of  the  inferior  second  molar  is  advocated  by 
some  operators  to  relieve  the  pain  caused  by  an  impacted  third 
molar.  The  author  does  not  favor  sacrificing  the  second  molar 
in  such  case,  although  it  is  a  comparatively  simple  procedure  to 
extract  that  tooth.     When  such  extraction  is  made,  it  is  more 

283 


284  EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 

frequently  a  failure  than  a  success  so  far  as  obtaining  the  desired 
relief  is  concerned,  and,  moreover,  the  subsequent  extraction  of 
the  third  molar  may  be  found  necessary.  It  is  therefore  better 
to  remove  the  involved  third  molar  at  the  outset,  and  leave  a 
good  second  molar  to  perform  its  function.  Some  operators  ex- 
tract the  inferior  second  molar  to  obtain  space  through  which  to 
remove  the  third  molar  when  it  is  impacted,  but  this  unnecessary 
destruction  of  a  valuable  organ  of  mastication  cannot  be  too 
strongly  disapproved,  and  such  a  procedure  is  not  countenanced 
in  the  practice  of  the  author,  as  the  impacted  third  molar  can  be 
removed  without  disturbing  the  second  molar. 

The  superior  third  molar  is  also  extracted  by  some  operators 
with  the  object  of  relieving  the  pain  from  the  impacted  inferior 
third  molar  under  the  impression  that  the  removal  of  the  supe- 
rior molar  will  avoid  pressure  on  the  tissues  over  the  impacted 
tooth,  or  that  the  inflammatory  condition  of  the  tissues  buccally 
and  distally  of  the  inferior  third  molar  is  due  to  injury  inflicted 
on  them  by  the  superior  third  molar.  This  may  give  temporary 
relief  in  some  cases,  but  is  seldom  effective,  as  there  would  be  no 
pressure  on  the  tissues  about  the  inferior  tooth  if  the  parts  were 
not  inflamed,  and,  as  the  inferior  third  molar  is  the  source  of  the 
inflammation,  either  by  direct  irritation  or  by  leaving  the  tissues 
about  it  in  a  condition  to  retain  debris  and  thus  invite  infection, 
the  extraction  of  the  inferior  tooth  is  necessary  to  remove  the 
cause  and  relieve  the  malady. 

Several  methods  have  been  devised  for  removing  an  inferior 
third  molar  when  it  is  impacted  by  its  crown  im])inging  on  the 
distal  surface  of  the  second  molar.  One  method  is  to  fasten  a 
metal  band,  with  a  spur  attached  to  its  disto-buccal  or  disto- 
lingual  side,  around  the  second  molar,  and  place  a  metal  ligature 
around  the  third  molar,  drawing  the  ligature  taut  over  the  spur 
in  an  endeavor  to  raise  the  third  molar.  The  ligature  is  drawn 
taut  each  day  until  the  third  molar  has  lieen  raised  far  enough 
from  its  abnormal  position  below  the  second  molar  to  allow  it  to 
be  extracted  without  interference  from  the  latter  tooth.  Another 
method  is  to  fasten  a  metal  band  on  both  second  and  third  molars, 
and  place  a  jackscrew  between  these  teeth,  the  ends  of  the  jack- 
screw  being  adjusted  respectively  against  the  liand  of  the  second 
and  third  molar.  The  jackscrew  is  lengthened  each  day  until  the 
third  molar  is  forced  distally  far  enough  to  relieve  its  impinge- 


ETIOLOGY  285 

ment  on  the  second  molar.  Either  of  these  methods  is  not  prac- 
ticable, and  can  be  used  only  where  the  roots  of  the  third  molar 
are  short,  or  where  there  is  not  too  great  an  impingement  on  the 
second  niohir.  If  the  associated  tissues  are  in  an  inflamed  state, 
such  procedure  will  cause  an  excruciating  pain  that  cannot  be 
endured  by  the  patient.  The  better  procedure  is  to  remove  the 
tooth  by  a  surgical  operation,  and  avoid  the  danger  of  increased 
inflammatory  conditions  that  may  arise  as  a  result  of  the  delay 
caused  by  completing  the  operation  by  any  of  the  methods 
mentioned. 

ETIOLOGY. 

A  careful  examination  should  be  made  to  determine  the  cause 
of  the  impaction,  which  is  probably  due  more  frequently  to  heavy 
gum  tissue  overlying  a  part  or  the  whole  of  the  occlusal  surface 
of  the  tooth,  but  is  sometimes  caused  by  the  superior  constrictor 
muscle  of  the  pharynx  or  by  the  buccinator  muscle.  The  origin 
of  these  muscles,  especially  the  buccinator,  may  extend  well  up 
on  the  alveolar  surface  of  the  body  of  the  mandible  at  and  for- 
ward of  the  angle  formed  by  it  and  the  anterior  border  of  the 
ramus,  and  have  their  attachments  directly  over  the  parts  of  the 
bone  that  is  being  displaced  by  the  erupting  third  molar.  When 
this  occurs,  it  is  not  uncommon  for  muscular  fibers  to  pass  over 
the  occlusal  planes  of  the  tooth,  carrying  with  them  a  mass  of 
mucous  and  submucous  tissue  which  is  abundant  in  this  region, 
and,  being  drawn  taut  into  the  sulci  of  the  tooth  by  its  eruption, 
most  effectually  ligate  the  tooth  in  the  position  it  has  taken  soon 
after  it  has  emerged  from  the  bony  structure. 

Other  causes  of  impaction  are:  (1)  where  the  alveolar  process 
extends  over  parts  of  the  occlusal  surface  of  the  tooth;  (2)  where 
a  dense  ledge  of  bone  projects  over  the  disto-occlusal  surface  of 
the  tooth;  (3)  where  the  tooth  is  so  far  imbedded  in  the  body  of 
the  mandible  that  little  or  no  alveolar  structure  is  formed  about 
it,  the  forces  of  development  being  insufficient  to  overcome  the 
resistance  offered  by  the  bony  structure;  (4)  where  the  third  or 
second  molar  is  in  malposition  and  there  are  abnormalities  in  the 
form  of  either  of  these  teeth,  as  when  the  crown  of  the  second 
molar  is  unusually  large  in  its  middle  diameter  compared  with 
its  gingival  diameter  and  engages  the  third  molar  below  this 
projection;  (5)  where  the  approximating  surfaces  of  the  second 


286  EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 

and  third  molars  are  broad  and  flat  instead  of  the  oval  shape 
peculiar  to  normal  teeth,  which  condition  may  compel  the  sliding 
of  one  broad  surface  over  the  other  to  complete  the  eruption  of 
the  third  molar;  (6)  where  there  are  supernumerary  teeth  about 
the  third  molar;  and  (7)  where  there  is  not  sufficient  space  be- 
tween the  second  molar  and  the  ramus  to  allow  the  passage  of 
the  third  molar. 

HISTORY  AND  NATURE  OF  THE  OPERATION. 

A  history  of  the  case  should  be  obtained  prior  to  operating 
on  an  impacted  inferior  third  molar.  The  patient  should  be 
questioned  as  to  the  duration  of  the  existing  condition  and  any 
previous  disturbance  that  may  ha\'e  been  caused  by  the  tooth, 
the  frequency  of  the  attacks  in  the  region  of  the  tooth,  and  the 
duration  and  severity  of  these  attacks.  As  far  as  possible,  the 
extent  of  the  inflammation  at  previous  attacks  should  be  ascer- 
tained, and  it  should  also  be  learned  if  any  previous  attempt  has 
been  made  to  extract-  the  tooth.  Frequently  a  patient  is  under 
the  impression  that  the  operative  procedure  of  extracting  an  im- 
pacted inferior  molar  is  similar  to  extracting  any  other  tooth. 
Where  this  idea  prevails,  and  if  the  operation  is  expected  to  be 
complicated,  the  operator  should  explain  to  the  patient  before 
extraction  the  character  of  the  operation,  using,  if  convenient,  a 
dry  specimen  or  a  picture  of  a  similar  case  for  the  purpose  of 
illustjation.  If  such  an  explanation  is  not  made,  and  the  opera- 
tion consumes  considerable  time,  causing  a  greater  disturbance 
of  the  tissues,  followed  by  more  pain  than  is  usual  with  ordinary 
extractions,  the  patient  may  become  apprehensive,  as  perhaps  on 
a  former  occasion  the  patient  had  some  other  tooth  extracted  and 
the  operation  was  a  very  simple  procedure,  or  some  friend  may 
have  had  a  third  molar  removed  with  little  difficulty. 

OPERATIVE  TECHNIC. 

In  giving  the  operative  technic  for  the  removal  of  the  numer- 
ous forms  of  impacted  third  molars  in  the  various  conditions  sur- 
rounding them,  the  most  practical  procedures  have  been  assigned 
for  the  different  cases  presented.  Numerous  cases  of  common 
occurrence  are  described  and  illustrated  in  such  manner  that 
each  step  in  the  technic  of  the  operation  may  be  thoroughly  un- 


PARTIAL  IMPACTION  287 

derstood  and  followed.  To  simplify  tlie  presentation  of  this  sub- 
ject, imj)actions  are  classified  as  partial  and  complete.  While  it 
may  not  always  be  possible  to  assign  each  individual  case  with 
certainty  to  the  class  to  which  it  belongs,  owing  to  the  different 
phases  of  the  numerous  cases  presented,  a  careful  study  of  the 
conditions  surrounding  each  case  will  usually  present  enough 
similarities  to  permit  a  proper  classification,  and  thus  enable  the 
operator  to  more  readily  outline  the  plan  of  operation. 

PARTIAL  IMPACTION. 

A  partial  impaction  refers  to  that  class  of  cases  where  the 
tooth  is  not  deeply  seated  in  the  tissues,  and  where  the  position 
of  the  crown  and  its  relation  to  the  surrounding  structures  can 
usually  be  determined  by  an  explorative  examination,  as  where 
the  eruption  is  retarded  a  short  distance  from  what  would  be  the 
normal  position  of  the  tooth  by  the  soft  tissues,  osseous  struc- 
tures, or  supernumerary  teeth,  or  where,  in  case  of  malposition, 
the  tooth  impinges  slightly  on  the  second  molar. 

Diagnosis. — A  correct  diagnosis  preceding  the  operation  is  a 
very  important  matter,  as  the  operative  procedure  will  be  gov- 
erned by  existing  conditions,  and  a  correct  knowledge  of  these 
conditions  in  each  case  should  be  obtained  as  a  guide  in  properly 
determining  the  technic  of  the  operation.  The  operator,  by  ex- 
amining the  part  of  the  crown  that  is  visible,  notes  the  position 
of  the  tooth  as  compared  with  what  would  be  its  normal  position 
if  fully  erupted,  and  ascertains  whether  it  impinges  on  the  crown 
of  the  second  molar,  determining  at  the  same  time  whether  the 
gum  tissue,  when  it  partially  overlies  its  occlusal  surface,  should 
remain  undisturbed  or  whether  it  will  be  necessary  to  make  an 
incision  before  applying  any  instrument  to  remove  the  tooth. 
The  probable  presence  of  foreign  bodies  or  supernumerary  teeth 
should  be  determined;  the  alveolar  process  should  be  examined 
to  ascertain  if  it  is  in  a  healthy  condition;  the  interproximal 
space  is  investigated  to  learn  whether  the  blade  of  the  Lecluse 
elevator  can  be  applied  between  the  second  and  third  molar ;  and 
the  second  molar,  if  it  is  in  alignment,  is  examined  with  a  view 
of  using  it  as  a  fulcrum.  If  the  operator  is  unable  to  satisfy 
himself  as  to  the  position  of  the  tooth  and  the  surrounding  con- 
ditions by  an  explorative  examination  conducted  without  injury 
to  the  parts,  a  radiograph  should  be  obtained. 


288 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


Anesthetic. — The  selection  of  a  suitable  anesthetic  should  be 
made,  as,  in  order  that  the  operation  may  be  successfully  exe- 
cuted, a  secure  adjustment  of  the  instrument  is  essential,  and, 
after  the  adjustment  has  been  made,  the  operation  must  proceed 
without  any  interference  on  the  part  of  the  patient.  Securing  a 
proper  adjustment  of  the  instrument  for  the  extraction,  espe- 
cially where  the  associated  tissues  are  in  an  inflammatory  condi- 
tion, will  inflict  considerable  pain.     In  such  case  a  local  anes- 


Fig-.   143. — A  dry  specimen  of  two  partially  impacted  inferior  third  molars. 


thetic  is  not  always  satisfactory,  and  it  is  advisable  to  admin- 
ister a  general  anesthetic — preferably  nitrous  oxid  and  oxygen. 
Partial  Impaction— %  Soft  Tissue.— -The  soft  tissue,  which  is 
more  frequently  the  cause  of  a  partial  impaction  than  any  other 
factor,  will  often,  when  it  is  heavy  and  resistant  over  the  occlusal 
surface  of  this  tooth,  retard  it  at  a  short  distance  from  its  normal 
position  (Fig.  143).  This  tissue,  which  is  not  shown  in  the  illus- 
tration, will,  when  in  the  shape  of  a  loose  flap,  often  form  pockets 
for  the  reception  of  debris,  which  will  continually  irritate  the 


PARTIAL  IMPACTION 


289 


tissue  surrounding  the  tooth,  and  in  most  cases  this  condition,  if 
of  long  standing,  can  be  relieved  onl}^  by  extraction. 

Where  the  examination  shows  that  the  crown  of  the  tooth  is 
assuming  a  normal  i)bsition,  but  its  occlusal  surface  is  slightly 
lower  than  the  occlusal  surface  of  the  second  molar,  and  the  gum 
tissue,  in  the  form  of  a  loose  flap,  partially  overlies  the  disto- 
occlusal  surface,  no  attention  should  be  paid  to  the  soft  tissue, 
and  extraction  should  be  performed  in  the  same  manor  as  where 
the  tooth  is  in  normal  occlusion. 

Frequently  the  soft  tissue,  when  it  overlies  the  major  position 
of  the  occlusal  surface,  can  be  easil}^  displaced,  and  does  not 
greatly  interfere  with  the  application  of  the  elevator  and  the 
raising  of  the  tooth  to  a  point  where  the  forceps  can  be  adjusted 
without  interference  from  the  tissue.  In  such  case,  as  when  the 
tissue  partially  overlies  the  disto-occlusal  surface,  the  elevator  is 


Fig.   144.— Model  of  a  iiaitially  impacti'd  intVriui-  third  molar.     The  gum  tissue  is  firmly 

adherent  about  the  crown. 


applied  without  severing  this  tissue  with  a  lancet  previous  to 
the  application.  If,  however,  it  is  observed  that  the  tissue  is 
firmly  adherent  about  the  tooth  (Fig.  144),  and  will  interfere 
with  the  application  of  the  instruments  and  the  extraction,  the 
lancet  should  be  used,  starting  the  incision  at  the  contact  point 
with  the  second  molar  at  about  the  center  of  the  occlusal  surface 
and  incising  distally  far  enough  to  expose  the  entire  crown.  In 
some  cases,  where  the  tissue  is  dense  around  the  distal  side,  it 
is  advisable  to  partially  sever  the  tissue  from  that  surface.  If 
the  operator,  while  dislodging  the  tooth,  and  not  having  previ- 
ously lanced  the  tissue,  observes  that  the  tissue  interferes  with 
the  delivery  of  the 'tooth  and  is  liable  to  be  lacerated,  he  should 
release  the  instrument  and  sever  the  tissue  from  about  the  tooth 
sufficiently  to  allow  it  to  be  released  without  causing  unneces- 
sary injury  to  the  parts. 


290 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


Where  the  crown  of  the  third  molar  is  slightly  lower  than  that 
of  the  occlnsal  plane  of  the  second  molar  and  is  inclining  distally, 
with  the  soft  tissue  partially  or  completely  covering  the  third 
molar,  the  method  of  operating  for  its  removal  is  the  same  as 
for  a  like  condition  of  the  tooth  not  covered  by  soft  tissue 
(page  272).  In  such  case  the  lancet  should  be  applied,  especially 
on  the  distal  side,  prior  to  adjusting  the  elevator  to  free  the 
parts  of  this  tissue,  so  that  there  will  not  be  any  interference 
from  it  during  the  extraction  movements. 

Bi/  Osseous  Tissue. — In  addition  to  the  eruption  of  the  tooth 
being  retarded  by  the  soft  tissue,  the  bony  tissue  also  will  retard 
its  eruption  and  interfere  with  the  application  of  an  instrument 
for  its  extraction,  especially  where  the  alveolus  extends  over  the 
occlusal  surface.     In  such  case  the  alveolus  should  be  cut  away 


Fig.  145. — 'Radiograph  of  a  partially  impacted  inferior  third  molar.  The  tooth  is 
retarded  a  short  distance  from  its  normal  position  by  the  osseous  tissue  over  its 
disto-occlusal  surface.     Tlie  third  molar  is  not  in  contact  with  the  second  molar. 

from  over  the  occlusal  surface  with  a  bur  or  chisel,  care  being- 
taken  to  remove  enough  process  to  insure  extraction,  which  is 
then  made  in  the  same  manner  as  though  the  tooth  had  not  been 
impacted  by  the  process. 

An  interesting  case,  and  one  not  frequently  presented,  is 
shown  in  Fig.  145.  In  this  case  the  alveolar  process  overlies 
the  disto-occlusal  surface  of  the  crown,  and  there  is  no  contact 
of  the  third  molar  with  the  second  molar.  In  such  case  the  ele- 
vator should  not  be  used,  as  its  use  would  only  force  the  tooth 
against  the  hard  tissues  on  its  distal  side,  and  the  tooth  could 
not  be  carried  from  its  position  in  this  direction.  The  removal 
of  such  a  tooth  is  accomplished  by  cutting  away  all  process  over 
the  occlusal  surface  and  enough  on  the  lingual  and  buccal  sur- 
faces to  permit  Standard  forceps  No.  7  (Fig.  8)  to  be  applied  to 
the  tooth.     When  the  forceps  have  been  adjusted,  a  slight  move- 


PARTIAL  IMPACTION 


291 


ment  to  the  lingual  side  is  made,  followed  by  a  forcible  tractile 
movement  to  deliver  the  tooth  from  its  socket. 

Where  both  the  gum  tissue  and  alveolus  overlie  the  crown,  and 
the  tissue  has  been  incised  and  the  alveolus  removed  in  the  man- 


Fig.  146. — A  partially  impacted  inferior  third  molar.  The  impingement  of  the  impacted 
third  molar  is  on  the  neck  of  the  second  molar.  The  disto-occlusal  surface  of  the 
crown  is  free  of  both  soft  and  hard  tissue. 

ner  described  above,  but  the  tooth  is  affected  by  caries  on  any  of 
its  surfaces,  the  operation  for  its  removal  is  the  same  as  that 
applicable  for  the  removal  of  an  inferior  third  molar  in  a  similar 
condition  of  decay  and  as  previously  described. 


Fig.  147. — Same  subject  as  Fig.  146.  Illustration  shows  the  application  of  the  Lecluse 
elevator  (Fig.  21)  between  the  second  and  third  molars  at  the  point  of  impinge- 
ment, and  the  third  molar  moved  distally. 

By  Malposition  and  Malformation. — Where  the  third  molar  is 

in  malposition  and  the  crown  is  slightly  lower  than  the  occlusal 
plane  of  the  second  molar,  and  impinges  on  the  latter  tooth,  but 
its  position  will  not  prevent  the  application  of  the  Lecluse  eleva- 


292 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


tor  (Fig.  21)  to  the  mesial  surface  of  the  crown,  and  the  gum 
tissue  and  alveolus  will  not  interfere  with  the  liberation  of  the 
tooth  (Fig.  146),  the  Lecluse  elevator  should  be  applied  in  the 
interproximal  space  between  the  second  and  third  molar  and 
from  the  buccal  side.  When  the  elevator  is  adjusted  (Fig.  147), 
the  tooth  is  loosened  by  turning  the  upper  end  of  the  handle 
mesially,  followed  bv  a  slight  pressure  downward  on  the  handle 
to  bring  the  crown  of  the  tooth  upward  to  a  point  where  it  can 
be  directed  distally.  When  the  tooth  is  sufficiently  loosened 
with  the  elevator,  the  forceps  are  adjusted  to  complete  the  ex- 
traction. 

A  radiograph  of  a  case  similar  to  the  one  described  is  shown 
in  Fig.  148,  but  the  second  molar  is  filled  on  the  distal  surface. 


Fig.  148. — Radiograph  of  a  jjaitially  im- 
pacted inferior  third  molar.  The  con- 
tact point  will  not  obstruct  the  ap- 
plication of  the  Lecluse  elevator 
(Fig.  21),  but  the  filling  in  the  second 
molar  will  prevent  the  use  of  the  lat- 
ter tooth  as  a  fulcrum. 


Fig.  149. — Radiograph  of  a  partially  im- 
pacted inferior  third  molar.  The 
crown  of  the  third  molar  impinges 
slightl.v  on  the  second  molar,  but  will 
not  prevent  the  application  of  the 
Lecluse  elevator.  The  process  is  heavy 
on  the  distal   side  of  the  third  molar. 


The  method  of  applying  the  elevator  in  this  case  is  modified,  and, 
instead  of  using  the  second  molar  as  a  fulcrum,  the  alveolas  is 
used  for  that  purpose.  The  flat  side  of  the  blade  of  the  Lecluse 
elevator  is  applied  to  the  mesial  side  of  the  third  molar,  and  a 
downward  pressure  is  exerted  on  the  handle  to  raise  the  tooth 
to  a  point  where  the  forceps  can  be  adjusted  to  complete  the 
extraction. 

Where  the  crown  of  the  third  molar  impinges  slightly  on  that 
of  the  second  molar,  but  does  not  interfere  with  the  introduction 
of  the  Lecluse  elevator  into  the  interproximal  space,  and  the 
osseous  tissue  on  the  distal  surface  of  the  crown  is  heavy,  as 
shown  in  Fig.  149,  which  is  a  radiograph  of  a  case  of  this  kind, 
a  part  of  the  osseous  structure  on  the  distal  side  should  be  re- 
moved before  the  elevator  is  applied.     The  method  of  procedure 


PARTIAL  IMPACTION 


293 


is  to  incise  the  soft  tissue,  which  is  not  shown  in  the  radiograph, 
a  little  further  than  the  point  to  which  the  operator  intends  to 
remove  the  bony  wall,  after  which  it  is  cut  away  with  a  fissure 
bur  from  the  distal  surface  of  the  tooth  to  such  an  extent  that, 
when  the  Lecluse  elevator  is  adjusted  for  the  extraction,  little 
resistance  will  be  encountered. 


Fig.  150. — A  partially  impacted  inferior  third  molar.  The  mesio-occlusal  surface 
impinges  on  the  second  molar,  and  the  contact  is  such  as  will  obstruct  the  appli- 
cation of  the  Lecluse  elevator  (Fig.   21)   to  the  mesial  surface  of  the  third  molar. 

Where  the  crown  of  the  third  molar  impinges  on  that  of  the 
second  molar  to  such  an  extent  that  it  interferes  with  the  intro- 
duction of  the  elevator  into  the  interproximal  space  (Figs.  150, 
151),  and  the  soft  tissues  and  process  on  the  distal  surface  of  the 


Fig.  151. — Model  of  a  partially   impacted  inferior   third   molar.     The  contact   point  will 
interfere  with  the  application  of  the  Lecluse  elevator  (Fig.  21)  to  its  mesial  surface. 

tooth  are  not  interfering  factors,  that  part  of  the  crown  of  the 
third  molar  that  interferes  with  the  applicaticm  of  the  elevator 
is  removed  with  a  fissure  bur  or  knife-edge  carburundum  stone. 
The  author  prefers  the  use  of  the  bur  (Fig.  152),  as  it  can 
be  kept  under  better  control,  and  there  is  not  the  liability  of 
injuring  an  adjacent  second  molar  or  an  opposing  tooth.     The 


294 


EXTRACTION  OB'  IMPACTED  INFERIOR  THIRD  MOLAR 


contact  point  that  impinges  on  the  second  molar  is  cut  away 
sufficiently  to  allow  the  Lecluse  elevator  to  freely  enter  the  in- 
terproximal space,  after  which  the  elevator  is  adjusted  and  the 
extraction  movements  follow  as  described  for  a  similar  case 
where  this  preliminary  procedure  is  not  necessary. 

Where  the  impingement  of  the  crown  on  the  second  molar 
interferes  with  the  adjustment  of  the  Lecluse  elevator,  and  the 
soft  and  osseous  tissues  interfere  on  the  distal  side  with  the  de- 
livery of  the  tooth  (Fig.  153),  the  contact  point  that  impinges  on 
the  second  molar  should  be  cut  away  as  described  above,  when 


Fig.  152. — Method  of  removing  tlie  contact  point  from  an  impacted  tliird  molar  with  a 
cross-cut  fissure  bur  to  permit  the  application  of  the  Lecluse  elevator  (Fig.  21). 

the  soft  tissue  is  lanced  and  enough  of  the  bony  tissue  removed 
on  the  distal  side  to  allow  the  tooth  to  be  as  readily  lifted  from 
its  socket  with  the  elevator  as  though  these  conditions  were  not 
present. 

Where  there  is  a  large  proximal  cavity  on  the  mesial  surface 
of  the  third  molar,  with  that  part  of  the  crown  impinging  on 
the  crown  of  the  second  molar,  and  the  surface  that  is  in  contact 
with  the  second  molar  is  not  strong  enough  to  su])port  the 
Lecluse  elevator  and  at  the  same  time  interferes  with  the  appli- 
cation of  this  instrument,  the  mastoid  chisel  (Fig.  41)  may,  in 


PARTIAL  IMPACTION 


295 


order  to  save  time,  be  used  instead  of  the  bur  to  cut  away  euougli 
of  the  third  molar  to  permit  the  elevator  to  be  adjusted.  The 
chisel  is  adjusted  from  the  buccal  side  to  the  part  of  the  third 
molar  that  interferes  with  the  application  of  the  elevator,  and 
with  a  blow  of  the  mallet  is  broken  down,  the  fractured  part 
being  removed  with  Derenberg  tweezers,  after  which  the  tooth 
is  released  with  the  Lecluse  elevator  in  the  manner  as  described 
above,  or  raised  to  a  point  where  the  extraction  can  be  completed 
with  the  forceps. 

Where  the  crown  of  the  third  molar  impinges  slightly  on  that 
of  the  second  molar,  and  the  roots  of  the  third  molar  are  not 
curved  or  inclined  distally,  the  usual  extraction  movements  as 
applied  with  the  elevator  will  not  always  loosen  the  third  molar, 
and  even  repeated  efforts  in  some  cases  will  not  have  any  effect 


Fig.  153. — Radiograph  of  an  impacted  inferior  third  molar.  The  crown  of  the  third 
molar  impinges  on  the  second  molar  and  prevents  the  application  of  the  Lecluse 
elevator  (Fig.  21).     The  osseous  structui'e  is  heavy  on  the  distal  side. 


on  it.  If,  after  the  application  of  the  ele^'ator  and  the  execution 
of  the  extraction  movements,  it  is  observed  that  these  movements 
have  no  eifect  on  the  tooth,  the  elevator  is  released  and  Standard 
forceps  No.  7  are  securely  adjusted,  when  the  tooth  is  directed 
to  the  lingual  side  just  far  enough  to  slightly  loosen  it  in  its 
socket.  As  soon  as  the  tooth  has  been  loosened  in  this  manner, 
the  elevator  is  applied  to  its  buccal  surface  and  the  tooth  is 
forced  lingually  and  upward,  after  which  it  is  lifted  from  its 
socket  with  the  forceps. 

Bt/  Su]K'rinimt'y(irii  Tccfh. — Cases  of  im])actod  third  molar 
caused  by  su])ei'uinnorary  teeth  are  not  of  frequent  occurrence, 
although  the  author  has  removed  in  a  single  case  as  many  as 
eight  small  supernumerary  teeth  tlint  were  imbedded  over  the 
crown  of  the  third  molar.     The  operation  in  such  cases  is  very 


296  EXTRACTION   OF  IMPACTED  INFERIOR   THIRD  MOLAR 

simple,  and  tlie  removal  of  the  supernumerary  teeth  precedes  the 
extraction  of  the  impacted  tooth  where  it  is  necessary  to  remove 
the  latter  to  relieve  the  condition,  the  impacted  tooth  being  taken 
out  l)y  whichever  method  is  applicable  to  the  class  of  cases  to 
which  it  belongs. 

COMPLETE  IMPACTION. 

A  complete  impaction  refers  to  that  class  of  cases  where  the 
tooth  is  deeply  seated  in  the  tissues,  and  where  the  position  of 
the  crown  cannot  be  determined  with  an  exploring  instrument, 
being  described  as  follows:  (1)  where  the  tooth  is  located  quite 
a  distance  from  the  occlusal  plane  of  the  second  molar;  (2)  where 
there  is  lack  of  space  between  the  ramus  and  the  second  molar 
for  the  third  molar  to  erupt;  (3)  where  the  tooth  is  inclined  or  in 
a  horizontal  position,  with  its  occlusal  surface  directed  toward 
or  impinging  on  the  crown,  neck,  or  distal  root  of  the  second 
molar;  (4)  where  the  tooth  is  malposed  in  any  direction,  and 
little  can  be  ascertained  of  its  relation  to  the  other  tissues  by 
explorative  examination.  If  an  extraction  is  attempted  in  any 
of  these  cases  without  a  thorough  diagnosis  having  been  obtained 
— if  necessary,  with  the  aid  of  the  radiograph — the  operation 
will  be  of  an  empirical  character,  with  probably  an  unnecessary 
destruction  of  tissue,  and  result  in  failure,  as  when  operating 
under  such  pronounced  uncertainties  the  inefficiency  and  danger 
of  misapplied  force  are  at  their  maximum,  with  the  consequent 
liability  to  fracture  of  tooth  or  osseous  structure,  and  the  re- 
moval of  the  cause  of  the  pathologic  condition  left  unaccom- 
plished. 

Radiographic  Diagnosis. — The  diagnostic  points  to  be  inter- 
preted from  a  radiograph  of  a  completely  impacted  third  molar 
are:  (1)  its  position  as  compared  with  what  would  be  its  normal 
position  if  fully  erupted;  (2)  the  distance  of  its  crown  below 
the  occlusal  plane  of  the  second  molar;  (8)  its  relative  position 
to  the  second  molar;  (4)  the  amount  of  its  surface  involved  if 
there  is  contact  with  the  second  molar;  (5)  the  size  of  its  crown 
and  roots,  and  the  division  of  the  roots  and  their  curvatures; 
(6)  the  amount  of  osseous  tissue  over  the  occlusal  and  distal 
surfaces  of  the  crown  and  its  distal  root;  (7)  the  available  space 
between  the  second  molar  and  the  ascending  raums  as  com]iared 
with  the  size  and  position  of  the  third  molar;  (8)  the  condition  of 


COMPLETE  IMPACTION 


297 


tlie  second  molar  and  tlie  amount  of  alveolar  process  sui^porting 
it.  The  radiograph  has  been  the  means  of  positive  diagnosis 
and  of  greatly  simplifying  the  operation  for  the  removal  of  these 
teeth.  By  its  use  the  operator  is  enabled  to  adopt  the  quickest 
and  least  complicated  method  of  obtaining  the  desired  result. 
The  small  film  for  intraoral  purposes  (page  88)  should  be  used 
where  possil)le  in  radiographing  this  tooth,  as  with  it  the  details 
are  lirought  out  more  clearly.  The  extraoral  method  of  radio- 
graphing is  used  only  where  temporary  ankylosis  is  present,  as 
in  that  case  it  is  not  practicable  to  insert  the  film  into  the  mouth 
to  obtain  a  radiograph.  The  extraoral  plate  will  give  the  posi- 
tion of  the  tooth  and  general  outlines,  but  lacks  the  liner  details 
produced  with  the  film. 

In  some  cases  the  radiograph  reveals  the  fact  that  the  patho- 


Fig.  154. — Radiograph  of  an  impacted  in- 
ferior tiiird  molar,  witii  a  large  cavity 
in  the  distal  root  of  the  second  molar. 


Fig.  1.5.5. — ^Radiograph  of  an  impacted  in- 
ferior third  molar,  with  a  large  cavity 
on  the  distal  side  of  the  second  molar. 


logic  condition  is  not  due  to  the  third  molar,  but  to  other  causes, 
and  thus  prevents  an  operation  which  would  not  relieve  the  con- 
dition. Fig.  154  shows  an  interesting  example.  The  patient  in 
this  case  had  experienced  considerable  pain  in  the  region  of  the 
second  and  third  molars.  As  the  tissues  surrounding  the  third 
molar  were  found  to  be  normal,  and  the  tooth  was  apparently  not 
giving  any  trouble,  the  filling  in  the  second  molar  was  removed 
by  the  attending  dentist  to  determine  whether  the  pulp  of  that 
tooth  was  involved.  The  examination  indicated  a  live  pulp,  and 
the  tooth  was  refilled,  the  third  molar  then  being  suspected  as 
the  cause  of  the  ])ain  on  account  of  its  mal)»()sition.  The  case 
was  referred  to  the  author,  and  a  radiogra])li  (Fig.  154)  was 
obtained  of  tlie  ))arts.  The  radiograph,  in  addition  to  showing 
the  condition  of  the  iiiipactiou,  also  showed  a  large  cavity  on  the 
distal  root  of  the  second  molar,  evidently  caused  by  the  pressure 


298 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


of  the  third  molar  against  the  tooth  at  this  point.  The  second 
molar  was,  therefore,  the  seat  of  the  disturbance  instead  of  the 
third  molar.  If  in  this  case  the  third  molar,  in  the  absence  of 
a  radiograph,  had  been  extracted,  the  second  molar  would  proba- 
bly have  been  fractured  or  loosened  by  the  operation  to  such  an 
extent  that  it  would  have  left  its  socket,  as  its  strength  had  been 
considerably  weakened  by  the  pressure  of  the  third  molar  upon 
it.  The  second  molar  was,  therefore,  extracted  and  the  third 
molar  allowed  to  remain.  Fig.  155  shows  a  case  similar  to  the 
one  just  mentioned. 

Another  interesting  example  is  shown  in  Fig.  156.  In  this 
case  a  number  of  attempts  had  been  made  to  extract  the  third 
molar,  and  the  history  given  by  the  patient  was  that  forceps  had 
been  repeatedly  used  on  it.     Each  attempt  had  evidently  re- 


Fig.  156.    Radiograph  of  an  impacted  inferior  third  molai-  in  a  horizontal  position.    The 
crown  of  the  third  molar  has  been  fractured  by  repeated  attempts  to  extract  it. 

suited  in  an  additional  fracture.  As  the  tooth  was  deeply  seated 
and  as  it  lay  in  a  horizontal  position,  a  correct  conception  of  the 
position  of  the  tooth  had  undoubtedly  not  Ijeen  obtained.  An 
attempt  to  extract  a  tooth  in  such  jDosition  by  applying  forceps 
to  its  crown  and  executing  a  tractile  movement  upward  would 
necessarily  result  in  a  failure.  In  this  case  the  radiograph  was 
of  great  value,  as  it  was  the  means  of  obtaining  a  correct  diag- 
nosis of  the  condition  and  thus  indicating  the  best  method  for 
extracting  the  tooth. 

Anesthetic. — Where  the  operation  is  not  difficult  and  will  con- 
sume only  a  short  time,  nitrous  oxid  and  oxygen  should  be  the 
anesthetic,  but  nitrous  oxid,  oxygen,  and  other  should  be  used 
where  the  tooth  is  very  deeply  seated  in  the  tissues,  or  where 
it  lies  in  a  horizontal  position,  or  where  it  is  so  inclined  mesially 


COMPLETE  IMPACTION  299 

tliat  the  greater  part  of  its  occlusal  surface  impinges  on  the 
second  molar,  or  where  the  roots  are  of  a  large  size,  or  hyper- 
cementosed,  or  markedly  divergent,  with  a  heavy  septum  between 
them,  and  are  not  curved  and  inclined  distally.  In  other  words, 
the  latter  combination  is  the  most  suitable  anesthetic,  and  should 
be  used  where  the  operation  will  consume  some  time,  or  where 
inflammation  is  so  extensive  as  to  cause  temporary  ankylosis. 
For  a  number  of  years  the  author  operated  in  his  office  on  cases 
of  the  character  mentioned  under  nitrous  oxid  and  oxygen  anes- 
thesia, but  his  experience  has  demonstrated  that  this  arrange- 
ment is  not  as  satisfactory  as  operating  on  such  cases  in  a 
hospital,  where  the  facilities  are  better  adapted  for  the  care  and 
after-treatment  of  the  patient  than  in  the  office  of  the  operator. 
The  operation  in  these  cases  is  strictly  a  surgical  procedure,  and 
the  operator  should  not  attempt  to  be  both  anesthetist  and  opera- 
tor. Experience  has  shown  that  the  attempt  of  the  operator  to 
keep  the  patient  anesthetized  with  nitrous  oxid  and  oxygen,  or 
to  depend  on  the  office  assistant  to  attend  to  it,  and  operate  at 
the  same  time  is  an  undertaking  fraught  with  great  danger,  as 
no  operator  can  properly  administer  the  anesthetic  and  effi- 
ciently execute  the  technic  of  the  operation.  It  is,  therefore, 
essential  in  these  cases  that  the  anesthetic  be  administered  by  a 
skilled  anesthetist,  so  that  the  operator  may  devote  his  entire 
attention  to  the  extraction. 

Complete  Impaction — B)i  Soft  Tissue. — Where  the  tooth  is 
deeply  seated  and  the  tissue  about  it  is  very  dense,  and  an  ex- 
ternal examination  seems  to  indicate  that,  if  the  eruption  were 
complete,  the  tooth  would  be  in  a  normal  position,  the  operator 
may  be  tempted  to  immediately  apply  an  instrument  in  an 
attempt  to  extract  the  tooth.  This  would  be  a  doubtful  pro- 
cedure, as  experience  has  shown  that  in  such  cases  there  may  be 
unexpected  conditions  that  would  militate  against  a  successful 
operation,  and  in  all  such  cases  it  is  advisable  to  obtain  a  radio- 
graph of  the  parts  before  attempting  extraction.  If  the  radio- 
graph shows  that  the  tooth,  in  addition  to  being  deeply  seated, 
has  a  tendency  to  erupt  toward  a  normal  position,  a  notation 
should  be  made,  among  other  points  to  be  determined,  of  the 
distance  of  the  tooth  from  the  occlusal  plane  of  the  second  molar. 
If  the  roots  are  distally  inclined,  if  there  is  no  process  over  the 
occlusal  surface,  if  the  osseous  structure  is  not  dense  on  the 


300 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


distal  side  of  the  crown  or  distal  root,  and  if  the  Lecluse  eleva- 
tor can  be  adjusted  to  the  crown,  the  procedure  for  its  extraction 
is  the  same  as  where  the  tooth  is  in  alignment,  the  soft  tissue 
over  the  occlusal  surface  being  incised  to  allow  the  tooth  to  be 
more  easily  liberated.  If,  however,  the  roots  are  not  distally 
inclined,  but  straight  and  fused  or  markedly  spread  (Fig.  157), 
Standard  forceps  No.  7  should  be  applied  and  the  extraction 
completed  with  this  instrument.  Before  applying  the  forceps, 
the  operator  should  ascertain  with  an  exploring  instrument 
whether  an  application  can  be  made  on  the  lingual  and  buccal 
surfaces  of  the  tooth.  If  such  an  application  is  not  practicable, 
the  bony  tissues  on  these  surfaces  are  burred  away  sufficiently 
to  allow  a  good  adjustment.  When  the  forceps  have  been  ap- 
plied, the  first  extraction  movement  is  forcibly  to  the  lingual 


Fig.  157. — Radiograph  of  a  completely  impacted  inferior  third  molar.  The  crown  is 
quite  a  distance  from  its  normal  position,  and  the  roots  are  almost  straight  and 
are  widely  separated. 

side,  followed  by  a  cautious  tractile  movement,  which  should 
loosen  the  tooth,  when  the  forceps  are  sent  further  down  on  the 
tooth  and  the  movements  repeated  until  the  tooth  is  extracted. 

By  Osseous  Tissue. — Where  the  tooth  is  deeply  seated  and  the 
osseous  tissue  is  over  the  occlusal  surface,  the  same  technic  is 
followed  as  where  this  condition  exists  and  the  tooth  is  partially 
impacted  (page  290),  but  a  radiograph  should  be  obtained  before 
extraction  is  attempted. 

Bt/  Insufficient  Space. — Where  the  tooth  is  deeply  seated  and 
there  is  insufficient  space  for  its  eruption,  the  crown  may  be 
directing  distally  and  the  hard  tissue  partially  or  completely 
overlying  its  occlusal  surface,  or  the  tooth  may  be  lying  at  an 
angle,  with  the  greater  part  of  its  crown  impinging  on  the  neck 
of  the  second  molar.  If  the  radiograph  reveals  that  the  crown 
is  markedly  inclined  distally  and  the  hard  tissue  is  dense  over 


COMPLETE  IMPACTION 


301 


the  occlusal  surface  (Fig.  158),  it  presents  one  of  the  most  diffi- 
cnlt  forms  of  impaction  encountered  with  this  tooth.  In  such 
case  the  elevator  cannot  be  applied  to  the  mesial  surface  of  the 
third  molar  for  the  purpose  of  directing  it  distally,  as  the  hard 
tissue  on  that  side  will  interfere;  and  it  will  he  impracticable  to 
apply  forceps  to  the  buccal  and  lingual  surfaces,  as  the  position 
of  the  crown  will  not  allow  a  movement  to  the  distal  side  or  a 
tractile  movement.  In  the  case  shown  in  Fig.  156  it  was  im- 
practicable to  obtain  an  intraoral  radiograph  with  a  film  on 
account  of  the  extensive  inflammation  of  the  gum  tissue,  and 
therefore  an  extraoral  radiograph  was  made.  As  much  of  the 
detail  on  the  plate  could  not  be  transferred  to  a  print,  a  drawing 
was  made  in  which  the  details  were  correctly  reproduced.  The 
gum  tissue  was  incised  on  the  lingual  side  to  a  point  slightly 


Fig.  158. — Radiograph  of  a  cuniijIctLly  iiiiiiacteil  inferior  tliird  molar,  tlie  imiiaction 
having  been  caused  by  insufficient  space.  Tlie  crown  is  mai'kedly  inclined  distally 
and  the  hard  tissue  is  dense  over  the  occlusal  surface. 

beyond  the  end  of  the  roots,  and  the  retractor  (Fig.  40)  placed 
in  position  to  hold  back  the  tissue,  when  the  alveolar  process  was 
cut  away  in  the  manner  described  for  removing  the  lingual  plate 
(page  311),  to  allow  the  tooth  to  be  liberated  toward  the  lingual 
side.  The  gum  tissue  over  the  occlusal  and  l)uccal  surfaces  was 
also  incised,  and  the  hard  tissue  removed  on  these  parts,  so  as  to 
allow  the  Lecluse  elevator  to  be  properly  adjusted. 

Where  the  entire  crown  impinges  on  the  second  molar,  and  the 
roots  are  fused  or  so  shaped  that  the  septum  between  them  is  of 
large  size,  and  the  hard  tissue  over  the  distal  surface  of  the  crown 
or  on  the  distal  side  of  the  distal  root  is  so  lieavy  that  the  tooth 
cannot  l)e  directed  distally  Avitli  an  elevator  or  upward  with 
forceps  (Fig.  159),  the  tooth  is  almost  as  difficult  to  remove  as 
when  the  crown  is  directed  distally,  with  the  osseous  tissues 
dense  over  the  distal  surface  of  the  crown.     In  such  case  a  radio- 


302 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


graph  should  be  made  of  the  parts  as  a  guide  for  the  operator. 
The  best  method  for  extractmg  such  tooth  is  to  cut  away  a  part 
of  the  lingual  plate  and  then  remove  enougli  of  the  hard  struc- 
ture on  the  distal  and  buccal  sides  to  allow  an  adjustment  of  the 
blade  of  the  Lecluse  elevator,  after  which  the  tooth  is  forced  to 
the  lingual  side  to  release  it. 


Fig-.  159. — Radiograph  of  a  completely  im- 
pacted inferior  thiid  molar.  Tiie  en- 
tire occlusal  surface  of  the  crown  of 
the  third  molar  impinges  on  the  sec- 
ond molar. 


Fig-.  ]<)0. — An  impacted  inferior  third  mo- 
lar in  horizontal  position.  The  third 
molar  is  small,  -with  fused  roots,  and 
is  not  in  contact  with  the  second 
molar. 


Bi/  Malpositio}i  (Old  MalforniafioN. — Where  the  impaction  is 
caused  by  malposition,  which  is  usually  associated  with  more  or 
less  malformation  of  the  third  molar  and  occasionally  of  the 
second  molar,  the  tooth  may  be  in  a  position  varying  from  a 
slight  inclination  from  the  perpendicular  to  a  complete  horizontal 
position.     The  shape  and  size  of  the  crown,  shape  and  direction 


Fig.   1,61. — Radiographs  of  impacted  inferior  third  molars  in  horizontal   position.    There 
is  little  process  over  the  distal  surface  and  slig-ht  contact  with  the  second  molar. 

of  the  roots,  amount  of  bony  tissue  over  the  distal  surface  of  the 
crown  and  distal  root,  and  the  position  and  amount  of  contact 
with  the  second  molar  govern  the  operative  technic  for  its  re- 
moval. 

Where  there  is  no  contact  with  the  second  molar  (Fig.  160),  or 
where  the  contact  is  only  slight,  and  the  osseous  tissue  over  the 


COMPLETE  IMPACTION  303 

distal  surface  of  the  distal  root  is  not  very  dense  or  extensive 
(Fig-.  161  )<  the  tooth  slioukl  l)e  removed  by  entting  away  with  a 
fissure  bur  a  part  of  the  hard  tissue  over  the  distal  root  and  from 
the  buccal  surface  of  the  crown.  The  Lecluse  elevator  is  then 
applied  to  the  buccal  surface  of  the  crown,  and  the  blade  forced 
down  and  under  the  crown  and  brought  mesially,  after  which 
pressure  is  exerted  downward  on  the  handle,  which  will  raise 
the  tooth  (Fig.  162).  "When  the  tooth  has  been  brought  to  this 
jooint,  the  second  molar  is  used  as  a  fulcrum  to  deliver  the  tooth 
from  the  socket. 


Fig.  1G2. — An  impacted  inferior  third  molar.     Illustration  shows  the  mesio-buccal  appli- 
cation of  the  Lecluse  elevator  (Fig.  21)  to  the  tooth. 

Cases  similar  to  the  one  described,  but  where  the  third  molar 
has  greater  contact  with  the  second  molar,  and  where  the  osseous 
structure  over  the  crown  and  distal  root  is  more  extensive  and 
denser,  with  one  or  both  of  the  roots  directed  upward  at  the 
apices,  are  shown  in  Fig.  163. 

The  method  of  operating  in  these  cases  is  to  cut  away  that  part 
of  the  crown  of  the  third  molar  that  impinges  on  the  distal  sur- 
face of  the  second  molar,  and  remove  a  part  of  the  bony  structure 
on  the  distal  side  of  the  third  molar.  The  part  that  is  in  contact 
with  the  second  molar  is  cut  away  with  a  fissure  bur,  as  descril)ed 


304  EXTRACTIONS!  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


towa7d^he  seconi  ,^nli^^'^^^^^^  *'^""'^  '""l^^^-     ^he   third  molar   is   inclined 

tooth      ThP  n^^Pm,«  1  il^,;.^-'*^v,  '^^  mesio-occlusal  surface  in  contact  with  the  latter 
tooth.     I  he  osseous  tissue  is  heavy  on  the  distal  side  of  the  third  molar. 


COMPLETE  IMPACTION 


305 


and  illustrated  for  such  procedure  in  the  case  of  partial  impac- 
tion (page  291).  The  process  is  then  burred  away  from  over  the 
distal  surface  of  the  third  molar  with  a  rose  or  fissure  bur  of 


Fig.  164. — An  impacted  inferior  third  molar.  Illustration  shows  the  method  of  inserting 
the  bur  under  the  free  margin  of  the  gum  to  remove  the  process  from  over  the 
distal  surface  of  the  tooth. 

suitable  size.  If  the  soft  tissue  over  the  tooth  is  not  very  firmly 
attached,  the  bur  can  be  passed  under  the  free  margin  of  the 
tissue  (Fig.  164)  to  the  margin  of  the  alveolus;  but,  if  the  tissue 


Fig.  1C5. — An  impacted  inferior  third  molar.  Illustration  shows  the  occlusal  surface 
of  the  crown  removed,  and  a  jiart  of  the  process  over  the  distal  surface  of  the 
tooth  cut  away. 

is  firmly  attached,  and  this  procedure  is  uot  ju-acticable,  an  in- 
cision is  made  with  a  lancet  and  the  tissue  held  back  with  the 
retractor  (Fig.  40),  so  that  the  bur  may  be  used  without  inter- 


306 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


ference  from  this  tissue.  The  bony  tissue  is  then  burred  away 
from  over  the  distal  side  of  the  tooth  to  al)out  the  extent  shown 
by  the  dotted  lines  in  Fig.  165,  followed  ]:)y  removing  a  part  of 
the  process  from  the  buccal  side  of  the  tooth.  The  Led  use  eleva- 
tor is  now  applied  and  the  point  of  the  blade  forced  down  on  the 


Fig-.  106. — An  impacted  inferior  third  molar.  The  apices  of  the  roots  are  directed 
ui)ward,  and  tlie  distal  surface  of  the  crown  of  the  second  molar  is  destroyed  to 
such  an  extent  that  the  latter  tooth  cannot  be  used  as  a  fulcrum. 

buccal  surface  of  the  crown,  bringing  the  blade  mesially,  when 
the  handle  is  jDressed  downward  to  raise  the  tooth  to  a  point 
where  the  second  molar  can  be  used  as  a  fulcrum  and  the  tooth 
directed  distally.  After  this  has  been  done,  the  forceps  are  ad- 
justed to  complete  the  removal  of  the  tooth,  which  is  accom- 


Fig.  167. — Same  subject  as  Fig.  166.  Illustration  shows  an  incision  of  the  gum  tissue 
on  the  buccal  side  of  an  impacted  third  molar  so  as  to  expose  the  process,  with 
the  retractor  holding  apart  the  soft  tissue. 

plished  by  bringing  it  slightly  to  the  lingual  side  and  then  upward 
and  posteriorly,  following  the  direction  indicated  by  the  inclina- 
tion of  its  roots. 

Where  the  second  molar  is  attacked  by  caries  on  its  distal  sur- 
face, and  the  tooth  cannot  be  used  as  a  fulcrum  for  the  elevator. 


COMPLETE  IMPACTION 


307 


the  operation  should  be  performed  independent  of  that  tooth.  If 
the  tliird  mohir  is  of  a  hirge  size,  and  the  roots  are  straight  and 
markedly  spread,  with  a  heavy  septnm  between  them,  the  lingual 
plate  is  removed,  as  described  on  page  oil,  to  release  the  tooth. 
If  the  tooth  is  of  average  size,  and  the  apices  of  the  roots  are 
favorably  inclined  upward  (Fig.  166),  the  bony  structure  on  the 
buccal  side  may  be  used  as  the  fulcrum  and  the  tooth  released 
with  the  Lecluse  elevator.  In  this  case  an  incision  about  half  an 
inch  in  length  is  made  in  the  gum  tissue  on  the  buccal  side  about 
in  line  with  the  mesial  surface  of  the  crown  of  the  third  molar, 
and  to  such  a  depth  that,  when  the  retractor  is  applied  to  hold 
the  flaps  apart,  the  bone  is  exposed  (Fig.  167).  The  bony  struc- 
ture is  then  cut  away  from  below  the  crown  with  a  bur  to  the  ex- 
tent shown  in  Fig.  168,  so  that  the  blade  of  the  elevator  can  be 


Fig.  168.— Same  subject  as   Figs.   166,    167. 
from   under   the   mesial    surface   of    tlie 
liolding-  apart  tlie  soft  tissue. 


Illustration   shows   the   hard   tissue  burred 
impacted    third   molar,    with   the   retractor 


adjusted  to  the  mesial  surface  of  the  crown.  When  sufficient 
space  has  been  obtained,  the  retractor  is  removed,  the  gum  tissue 
over  the  crown  is  then  incised  if  necessary,  and  enough  of  the 
osseous  tissue  over  the  distal  side  is  removed  to  permit  the  deliv- 
ery of  the  tooth.  The  contact  of  the  tooth  with  the  second  molar 
having  been  relieved  by  decay,  it  is  seldom  necessary  to  remove 
any  of  the  occlusal  surface  of  the  third  molar.  The  elevator  is 
now  inserted  in  the  space  created  for  it  on  the  mesial  side  or 
under  the  crown  of  the  third  molar,  the  alveolar  ridge  on  the 
buccal  side  is  used  as  a  fulcrum,  and  a  downward  pressure  is 
exerted  on  the  handle  of  the  elevator  to  prize  the  tooth  upward. 
If  this  does  not  loosen  the  tooth,  the  blade  of  the  elevator  is  sent 
further  down  below  the  crown  and  the  prizing  repeated.  As 
soon  as  the  tooth  is  loosened,  it  is  raised  from  the  socket  by  fore- 


308     ■      EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


Fig.  169. — Radiographs  of  completely  impacted  inferior  third  molars.  The  teeth  are 
in  horizontal  position,  with  all  or  nearly  all  of  the  occlusal  surface  of  the  crown 
ot  the  third  molar  impinging  on  the  second  molar. 


COMPLETE  IMPACTION 


309 


ing  the  blade  of  the  elevator  still  further  between  the  crown  and 
bony  wall,  after  which  the  tooth  is  seized  with  the  forceps  and 
the  extraction  completed. 

"Where  all  or  nearly  all  of  the  occlusal  surface  of  the  crown  of 
the  third  molar  impinges  on  the  second  molar  (Fig.  169);  or 
where  the  osseous  tissue  over  the  distal  surface  of  the  crown  and 
distal  root  is  very  dense  (Fig.  170);  or  where  the  impingement 
of  the  third  molar  is  on  the  neck  or  root  of  the  second  molar,  and 
the  roots  are  completely  or  nearly  fused  and  have  little  curvature 
(Fig.  171) ;  or  where  there  is  an  impingement  on  the  second 
molar,  with  the  roots  markedly  spread  or  hooked  (Figs.  172, 
173,  174),  the  operation  described  for  removing  the  process  over 
the  distal  side  of  the  tooth,  and  cutting  away  that  part  of  the 
crown  that   impinges   on   the   second  molar,   is  not   indicated. 


Fig. 


170. — Radiographs   of  impacted   inferior   tliird    molars.     There    is   heavy   osseous 
tissue  over  the  distal  surface  of  the  crown  or  distal  root  of  the  molar. 


Where  these  conditions  exist,  the  preferred  technic  of  operation 
is  to  remove  the  lingual  plate.  Impacted  teeth  of  the  character 
described  have  been  extracted  by  the  author  in  almost  every  con- 
ceivable manner  that  seemed  at  all  rational,  and  the  most  heroic 
method  adopted  in  any  case  was  that  of  using  splitting  forceps, 
applying  them  so  as  to  sever  the  tooth  in  half  in  order  that  first 
the  crown  and  then  the  roots  could  be  removed.  The  traumatic 
injuries  that  were,  however,  produced  in  all  the  methods  that 
were  used  demonstrated  the  necessity  of  a  less  destructive  opera- 
tion, and  efforts  to  develop  a  method  of  extraction  in  these  ex- 
tremely difficult  cases  that  would  be  efficacious  and  also  cause  a 
minimum  amount  of  destruction  to  the  parts  led  to  the  procedure 
of  removing  the  lingual  plate  of  the  alveolar  process  as  the  most 
satisfactory  method  of  operating  in  a  majority  of  such  cases. 


310  EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


Fig.  171.— Radiograph  and  model  of  impacted  inferior  third  molar.s.  .1,  the  me.sio- 
occlusal  surface  of  the  third  molar  imping-es  on  the  neck  of  the  second  molar,  the 
ro9ts  of  the  impacted  tooth  being  partially  fused;  B,  the  occlu.sal  surface  of  the 
third  molar  impinges  on  the  neck  and  crown  of  the  second  molar,  the  roots  of  the 
impacted  tooth  being  separated,  with  the  septum  between  the  roots. 


COMPLETE  IMPACTION 


311 


Removing  the  Lingual  Plate. — Figures  169  to  174  present  con- 
ditions where  the  removal  of  the  lingual  plate  is  indicated.  In 
these  cases  the  occlusal  surface  of  the  crown  of  tlie  third  molar 
impinges  on  the  second  molar.  The  third  molar  is  in  many  of 
these  cases  situated  in  a  position  that  at  first  suggests  the  opera- 
tion described  for  cutting  away  that  portion  of  its  crown  that  is 
in  contact  w^itli  the  second  molar  and  removing  the  bony  struc- 
ture over  its  distal  surface  as  a  preliminary  to  its  extraction,  but 
the  roots  of  the  third  molar,  being  fused  and  not  favorably  in- 


Fig.  172. — Radiographs  of  impacted  inferior  third  molars.  The  occlusal  surface  of  the 
third  molar  impinges  on  the  second  molar,  with  the  roots  of  the  impacted  tooth 
markedly  spread  or  hooked. 


clined  upward,  and  hooked  or  rather  widely  separated,  with  the 
septum  between  them  heavy  and  dense,  would  interfere  with  the 
delivery  of  the  tooth  even  if  the  jn'ocess  and  contact  points  were 
removed.  In  addition  to  this  interference,  the  large  area  of  the 
occlusal  surface  of  the  third  iiiolai',  which  is  composed  of  enamel, 
that  is  in  contact  with  tlie  second  molar  would  cause  llie  opei-a 
tion  of  cutting  away  tlie  surl"ac<'  impinging  on  tlie  second  molar 
to  consume  too  much  time,  and  it  is  therefore  advisable  in  these 
cases  to  remove  the  lingual  plate  for  the  delivery  of  the  tooth. 


312 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


An  incision  of  the  soft  tissue,  a  little  longer  than  the  length  of  the 
roots  of  the  third  molar,  as  shown  hy  a  radiograph,  is  made  over 
the  lingual  side  of  the  tooth  with  curved  scissors  (Fig.  175),  and 


\ 


Fig.  173  —Impacted  third  molars.     The  occlusal  surface  of  the  third  molar  impinges  on 
tne  second  molar,  with  the  roots  of  the  impacted  tooth  markedly  hooked. 

the  retractor  (Fig.  40)  is  placed  in  position  to  hold  back  the  flaps 
of  this  tissue,  the  instrument  being  held  by  the  operator  or  his 
assistant.     The  blood  from  the  incision  is  removed  with  gauze  or 


COMPLETE  IMPACTION 


313 


l^^^^l 

'           > 

^^^^^^^^^^B 

^^^^^BL  1^' 

M'^' 

Pi 

J 

^^Bcr^-' 

Z^ 

^^^3 

Fig.   174. — Models   of   impacted    tliird    molars.     The   occlusaV  surface   of    Ihe    third   molar 
impinges  on  the  second  molar,  with  the  roots  of  the  impacted  tooth  markedly  hooked. 


314 


EXTRACTION  OF  IMPACTED  INFERIOR  THIRD  MOLAR 


absorbent  cotton,  as  may  be  necessary,  to  keep  clear  the  field  of 
operation.     A  large  bur,  or  one  of  Scliamb erg's  surgical  burs, 


~i^.  ,-tt 


Fig.  175. — A  completely  impacted  inferior  thiid  molar.  Illustration  shows  the  method 
of  making-  an  incision  with  curved  .scis.sors  (Fig.  34)  into  the  gum  tissue  on  the 
lingual  side  of  the   tooth  to  expose  the  hard  tissue. 

wliicli  lias  been  previously   inserted   in   the   hand-piece  of  the 
dental  engine,  is  a])plied  to  the  margin  of  the  alveolus  and  the 


Fig.  176. — Same  subject  as  Fig.  17-i.  Illustration  shows  the  gum  tissue  held  apart  with 
the  retractor  and  the  process  being  removed  from  the  lingual  side  of  the  third 
molar. 

process   is  cut  away    (Fig.   176),   the   cutting   being  continued 
toward  the  apices  of  the  roots  until  the  process  over  both  roots 


COMPLETE  IMPACTION 


315 


is  removed,  Witli  a  rose  or  fissure  bur  of  suitable  size,  in  a  right- 
angled  hand-piece,  the  process  between  the  roots  is  then  removed, 
as  its  presence  will  interfere  with  the  extraction  of  the  tooth. 


Fig.   177.— Same  .subject  as   Figs.   175.   176.     Illustration  f-hows  the   extent   to   which   the 
lingual  plate  is  removed  before  applying  the  elevator  to  the  third  molar. 

When  the  alveolar  process  has  been  removed  to  the  extent  shown 
in  Fig.  177,  the  retractor  is  detached  and  the  Lecluse  elevator  is 
applied  to  the  buccal  surface  of  the  tooth  (Fig.  178)  with  sufficient 


Fig.  178.-Same  subject  as  Figs.  175,  176,  177.  Ill"/tration  shows  the  application  of 
the  Lecluse  elevator  (Fig.  21)  to  the  buccal  surface  of  the  thud  molai  to  di&lodge 
it  after  the  ling-ual  plate  has  been  removed. 

pressure  to  force  the  tooth  lingiially  tliroiigii  tlio  space  tliat  has 
been  created  for  its  exit.  It  is  advisabk'  to  remove  enough  of 
the  lingual  i)late  to  iiermit  unobstructed  delivery  of  tlie  tooth 
rather  than  attempt  to  force  the  tooth  from  its  position  by  ex- 
cessive force  applied  with  the  elevator. 


CHAPTER  XII. 
DECIDUOUS  AND   SUPERNUMERAEY  TEETH. 

Where  there  has  been  absorption  of  the  root  of  a  deciduous 
tooth,  and  it  is  very  loosely  attached  to  the  gum  tissue,  extrac- 
tion can  often  be  performed  by  wrapping  a  piece  of  antiseptic 
gauze  around  the  thumb  and  index  linger,  grasping  with  these 
two  digits  the  tooth  on  the  lingual  and  labial  surfaces,  and 
directing  a  pressure  alternately  lal)ially  and  lingually  until  it 
is  loosened  from  the  tissue,  when  it  is  lifted  from  its  position. 
This  method  does  not  tend  to  frighten  the  child,  which  is  often 
alarmed  when  forceps  are  used.  When  this  procedure  is  not 
practicable,  it  becomes  necessary  to  use  the  elevator  or  forceps. 

Supernumerary  teeth  should,  as  a  rule,  be  extracted,  as  they 
are  usually  situated  where  they  cause  an  unsightly  appearance, 
or  where  their  presence  prevents  a  natural  tooth  from  assuming- 
its  normal  position ;  or  they  irritate  the  gum  or  other  soft  tissue, 
or  prevent  the  proper  cleansing  of  the  normal  teeth.  Their 
removal  is  seldom  a  difficult  operation,  but  should  be  accom- 
plished in  such  a  manner  as  not  to  disturb  adjacent  teeth. 

DECIDUOUS  TEETH. 

Position  of  Patient  and  Operator. — The  position  of  the  patient 
and  operator  when  extracting  deciduous  teeth  is  as  described 
(page  99). 

Anatomy. — Before  the  operator  attempts  any  operation  on  de- 
ciduous teeth,  he  should  possess  a  knowledge  of  their  anatomy, 
of  the  order  in  which  they  will  be  replaced  by  the  permanent 
teeth,  and  of  the  period  of  life  at  which  they  will  likely  be  re- 
placed. While  the  time  of  their  loss  varies  greatly  with  indi- 
viduals, a  fair  knowledge  of  such  time  may  be  obtained  in  each 
case  by  comparing  with  the  age  of  the  child  the  deciduous  teeth 
that  have  been  lost  and  those  that  remain,  and  any  of  the  perma- 
nent teeth  that  may  have  erupted.  The  effect  that  the  loss  of  a 
deciduous  tooth  will  have  on  the  position  to  be  occupied  by  the 

316 


DECIDUOUS  TEETH  \  317 

permanent  tooth,  and  the  effect  that  this  loss,  if  a  premature 
one,  will  have  on  tlie  development  or  lack  of  development  of  the 
arch,  should  be  carefully  prognosticated,  and,  if  there  is  doubt 
concerning  this  probable  effect,  a  competent  orthodontist  should 
be  consulted. 

Attitude  of  the  Operator. — The  operator  should  gain  the  con- 
fidence of  the  child  by  kindly  persuasion  if  such  course  is  neces- 
sary, not  concealing  the  probability  of  a  little  pain,  though  giv- 
ing assurance  that  he  will  be  very  gentle.  No  deception  should 
be  practiced  or  forcible  extraction  attempted,  as  otherwise  it 
will  be  difficult  to  have  the  patient  submit  to  subsequent  opera- 
tions, for  such  experiences  are  very  vividly  and  indelibly  fixed 
in  the  mind  of  the  little  patient. 

Anesthetic. — If  the  extraction  will  cause  severe  pain,  the  ad- 
ministration of  nitrous  oxid  and  oxygen  is  advised.  The  little 
patient  sometimes  interferes  with  the  operator,  and  it  is  just  as 
important  that  he  be  anesthetized  as  an  adult  where  conditions 
make  it  necessary,  as  the  pain  of  extracting  deciduous  teeth  is 
as  great  as  that  of  extracting  the  permanent  teeth  when  the  age 
of  the  patient  is  considered.  In  addition  to  this  condition,  the 
deciduous  molars  normally  have  roots  that  are  widely  divergent, 
and  may  be  quite  as  difficult  to  remove  as  the  permanent  teeth  if 
absorption  has  not  paved  the  way  for  their  loss,  and  such  cases 
are  commonly  presented  for  extraction.  The  little  one  has  less 
reasoning  capacity  and  less  self-control  than  an  adult,  and  will 
consequently  resist  a  painful  operation  more  strenuously,  which 
may  result  in  an  accident,  and  the  operator  should  always  guard 
against  interference  from  the  hands  or  closure  of  the  mouth. 

Superior  Incisors  and  Cuspids. — The  extraction  of  the  decidu- 
ous central,  lateral,  and  cuspid  teeth  is  a  comparatively  simple 
procedure,  as  their  attachments  to  the  supporting  tissues  are  not 
very  firm.  Where  the  crown  is  intact  and  free  of  caries.  Stand- 
ard forceps  No.  1  (Fig.  1)  should  be  used.  Usually  the  applica- 
tion of  the  beaks  of  these  forceps  on  the  tooth,  with  a  slight 
amount  of  pressure,  will  detach  the  tooth.  If  any  resistance  is 
encountered,  the  tooth  is  moved  alternately  to  the  labial  and 
lingual  sides,  and,  if  necessary,  a  slight  rotatory  movement  may 
be  made.  If  the  crown  is  decayed  and  frail,  and  insufficient 
structure  remains  for  Standard  forceps  No.  1  to  be  applied. 
Standard  forceps  No.  5  (Fig.  6)  should  be  used,  care  being  taken 


318  DECIDUOUS  AND  SUPERNUMERARY  TEETH 

in  tlieir  application  that  tlie  beaks  do  not  intrude  on  the  j)erma- 
nent  erui^ting  tootli.  If  only  a  small  part  of  the  crown  or  root 
remains,  the  straight-shank  or  Cryer  elevator  (Figs.  15,  21) 
should  be  used  and  the  blade  applied  in  such  manner  that,  when 
adjusted,  a  pressure  of  a  pushing  nature  exerted  labially  will 
dislodge  the  remaining  part.  If  the  apex  of  a  root  protrudes 
through  the  gum  tissue,  the  root  should  be  extracted  with  the 
straight-shank  elevator,  adjusting  it  so  that  a  downward  pres- 
sure may  be  applied  against  the  apex  of  the  root,  which  will 
usually  force  the  root  from  its  socket. 

Care  must  be  exercised  in  the  extraction  of  deciduous  teeth, 
so  that  the  gum  tissue  is  not  torn  by  the  operation.  If  absorp- 
tion has  been  rather  complete,  the  soft  tissue  adheres  more  tena- 
ciously to  the  necks  of  the  deciduous  than  to  the  permanent 
teeth,  and  no  tractile  movement  should  l)e  executed  until  this 
tissue  has  been  detached  from  the  tooth.  Detaching  the  tissue 
is,  however,  a  simple  procedure  if  suitable  forceps  have  been 
selected,  as  a  judicious  application  of  the  beaks  to  the  neck  of 
the  tooth,  followed  by  a  labio-lingual  movement,  will  readily 
sever  this  tissue  from  the  tooth. 

Superior  First  and  Second  Molars. — Where  the  greater  part 
of  the  crown  of  a  deciduous  superior  first  or  second  molar  is 
intact,  Standard  forceps  No.  4  (Fig.  5)  should  be  used.  The 
beaks  are  carefully  adjusted  to  the  tooth,  and  the  extraction 
movements  to  be  applied  are  similar  to  those  descriljed  for  re- 
leasing the  permanent  tirst  molar  (page  159).  If  the  crown  is 
extensively  decayed,  and  Standard  forceps  No.  4  cannot  be  se- 
curely adjusted,  but  sufficient  structure  remains  for  Standard 
forceps  No.  2  (Fig.  2)  to  be  applied,  the  latter  instrument  is  used 
and  the  same  extraction  movements  are  executed.  If  only  the 
root  remains  and  it  is  fragile.  Standard  forceps  No.  5  (Fig.  6) 
are  used,  and  should  be  carefully  adjusted,  so  that  the  beaks  do 
not  come  in  contact  with  the  erupting  permanent  tooth.  If  only 
the  outer  walls  of  the  crown  or  part  of  the  root  remains,  the 
Cryer  elevator  is  used,  adjusting  the  instrument  so  that  the  first 
application,  which  is  made  with  a  degree  of  pressure  according 
to  the  size  of  the  structure  remaining  and  the  firmness  of  its 
attachment,  will  release  the  parts. 

Inferior  Incisors  and  Cuspids.— The  crowns  and  roots  of  the 
inferior  deciduous  incisors  and  cuspids  are  small.     These  teeth 


SUPERNUMERARY  TEETH  319 

do  not  offer  any  appreciable  resistance,  and  tlie  extraction  move- 
ments for  their  release  are  practically  the  same  as  those  for  the 
corresponding  permanent  teeth.  Standard  forceps  No.  6  (Fig.  7) 
or  Standard  forceps  No.  8  or  No.  9  (hawksbill,  Figs.  9,  10)  may 
be  ai)plied,  care  l)eing  taken  to  obtain  a  good  adjustment  of  the 
beaks  and  not  to  release  an  adjacent  tooth  Ijy  the  operation. 

Inferior  First  and  Second  Molars. — The  extraction  of  the  in- 
ferior deciduous  first  and  second  molars  is  usually  performed 
with  Standard  forceps  No.  7  (Fig.  8)  when  the  greater  part  of 
the  crown  is  intact  and  the  tooth  is  still  firmly  attached  to  its 
tissue.  If  the  application  of  the  beaks  of  the  forceps  on  the 
tooth  does  not  release  it,  the  extraction  movements  should  be  to 
sway  the  tooth  alternately  from  the  buccal  to  the  lingual  side  to 
detach  it,  and  then  with  a  tractile  movement  upward  carry  it 
from  its  socket.  If  the  crown  is  not  firaily  attached,  or  only  the 
roots  remain,  the  straight-shank  elevator  should  be  applied — to 
the  buccal  surface  of  the  tooth  when  operating  on  the  right  side 
of  the  arch,  and  to  the  lingual  surface  when  operating  on  the  left 
side — and  a  pressure  of  a  pushing  nature  is  exerted  to  carry  the 
root  from  its  socket  lingually  in  the  former  case  and  buccally  in 
the  latter.  If  only  the  roots  remain,  and  they  are  small  and 
firmly  attached,  the  Cryer  elevator  is  applied  to  release  them. 

Wedged  Roots  of  Deciduous  Teeth. — The  roots  of  deciduous 
teeth  often  Ijecome  wedged  between  the  erupting  crowns  of  per- 
manent teeth,  frequently  making  it  difficult  to  gain  access  to  the 
deciduous  tooth  for  its  extraction  without  endangering  the  per- 
manent tooth.  In  such  case  the'  extraction  can  often  be  accom- 
plished by  employing  as  an  elevator  an  ordinary  enamel  chisel. 
The  instrument  is  applied  in  such  manner  that  the  root  can  be 
pushed  from  its  attachment,  access  being  gained  from  the  most 
favorable  angle,  and  pressure  is  exerted  in  the  direction  that  will 
most  readily  permit  the  exit  of  the  root  without  endangering  the 
permanent  tooth.  If  the  parts  remaining  are  of  considerable 
size,  the  straight-shank  elevator  is  used  in  the  same  manner  as 
the  chisel. 

SUPERNUMERARY  TEETH. 

The  general  ap]xnirance  of  supernumerary  teeth,  which  is  most 
commonly  the  primary  tooth  form,  or  a  grouping  of  these  forms 
imperfectly  bound  together,  is  such  that  they  cannot  be  mistaken 


320 


DECIDUOUS  AND  SUPERNUMERARY  TEETH 


for  normal  teeth  (Fig.  179).  If  supernumerary  teeth  are  present, 
they  are  usually  located  in  the  region  of  the  ten  superior  anterior 
teeth,  but  are  occasionally  found  in  the  region  of  the  molar  teeth. 
Supernumerary  teeth  usually  cause  irregularities,  and  often  pre- 
vent the  eruption  of  the  permanent  teeth. 

Extraction  Technic. — Where  the  crown  of  a  supernumerary 
tooth  approximates  the  size  of  a  normal  tooth,  the  extraction  is 
made  in  the  same  manner  as  described  for  the  corresponding 
normal  tooth.  Fig.  180  shows  a  supernumerary  lateral  incisor 
that  is  causing  an  irregularity,  and  its  extraction  would  mate- 


MMMIf 


Fig.   179. — Types  of  supernumerary  teeth. 

rially  help  to  correct  the  condition.  In  such  case  Standard  for- 
ceps No.  1  should  be  applied,  and  the  tooth  extracted  in  the  man- 
ner described  for  the  extraction  of  the  lateral  incisor  (page  122). 
Peg-Shaped  Crown.— Where  the  crown  of  a  supernumerary 
tooth  is  of  a  peg-shape,  forceps  should  be  selected  that  will  cover 
the  major  surface  of  that  part  of  the  crown  projecting  through 
the  soft  tissue,  and  the  adjustment  must  be  carefully  made,  as  the 
crown  may  be  extremely  conical  in  shape.  In  such  case  the  mar- 
gin of  the  alveolus,  if  it  extends  over  the  base  of  the  cone,  should 
be  cut  away  sufficiently  from  about  the  tooth  with  a  fissure  bur  to 
allow  a  secure  adjustment  of  the  forceps,  when  the  extraction 


SUPERNUMERARY  TEETH 


321 


movements  should  be  made  in  the  direction  of  least  resistance. 
Care  should  be  taken  to  avoid  fracturing  the  crown,  and,  if  firm 
resistance  is  encountered,  more  of  the  alveolus  should  be  cut 


Fig.  180. — A   model   showing   a   supernumerary   tooth   occupying   the   position    of   the 
superior  right  lateral  incisor. 

away  and  the  beaks  of  the  forceps  sent  further  on  the  tooth  to 
assist  in  releasing  it  by  this  extraction  movement  rather  than 
fracture  the  tooth. 

Supernumerary  Teeth  in  the  Vicinity  of  the  Superior  Bicuspids 
and  Molars. — Small  supernumerary  teeth  are  occasionally  located 
on  the  buccal  side  of  the  superior  bicuspids  and  molars,  and 


Fig.  181. — Fusion   of  a  supernumerary  tooth   with  a  bicuspid. 


when  so  situated  it  is  usually  impracticable  to  apply  the  forceps 
for  their  removal,  it  often  being  difficult  to  adjust  even  the  fine- 
beak  Standard  forceps  No.  5  to  them.  When  the  latter  forceps 
are  not  indicated,  the  Cryer  elevator  should  be  used.  A  supple- 
mental cusp  must  not  be  confused  with  a  supernumerary  tooth, 
and  where  a  supernumerary  tooth  is  fused  to  a  normal  tooth, 


322 


DECIDUOUS  AND  SUPERNUMERARY  TEETH 


which  is  sometimes  the  case  (Figs.  181,  182),  such  peculiarity 
must  be  noted,  for,  if  this  condition  exists  and  is  not  observed, 
the  normal  tooth  may  be  disturbed  l^y  the  operation.  The  ele- 
vator is  applied  between  the  normal  and  supernumerary  tooth, 
and,  if  the  supernumerary  tooth  is  loosened  by  this  application, 
the  blade  of  the  elevator  is  sent  further  between  the  two  teeth, 
and  the  procedure  continued  until  the  tooth  is  free  from  its 
attachment. 

Where  a  supplemental  cusp  is  present,  or  where  there  is  a 
union  of  a  supernumerary  and  normal  tooth,  resistance  will  be 
encountered,  in  which  case  the  tooth  is  left  undisturbed.  The 
author  has  seen  a  numl)er  of  cases  where  a  supplemental  cusp 
was  mistaken  for  a  supernumerary  tooth  and  where  a  supernu- 
merary tooth  was  fused  to  a  permanent  tooth,  and  the  forcible 


Fig.  182. — Superior  left  molar  with  a  supernumerary  tooth  projecting  from  the  middle 
third  of  the  lingual  root.  The  crown  of  the  .supernumerary  tooth  resembles  a 
superior  bicuspid. 


extraction  that  bad  been  attempted  by  adjusting  the  forceps  to 
the  cusp  or  to  the  supernumerary  ci'own  resulted  in  the  loss  of  the 
permanent  tooth. 

Very  Small  Teeth. — Supernumerary  teeth  of  a  very  small  type 
are  occasionally  imbedded  in  the  soft  tissue  over  the  crown  of  a 
permanent  tooth  and  prevent  its  eruption.  The  removal  of  these 
small  teeth  can  be  best  accomplished  with  Standard  forceps  No.  5 
(Fig.  6)  when  located  in  the  superior  arch  and  with  Standard 
forceps  No.  6  (Fig.  7)  when  located  in  the  inferior  arch.  Usually 
a  firm  adjustment  of  the  beaks  of  these  forceps,  with  a  slight 
rotatory  movement,  will  release,  them.  When  these  teeth  are 
deeply  seated  and  are  overlaid  with  the  gum  tissue,  they  should 
be  extracted  by  making  an  incision  of  the  soft  tissue  and  apply- 
ing the  Cryer  elevator  to  loosen  them,  after  which  they  are  deliv- 
ered from  their  imbedded  position  with  the  Derenberg  tweezers. 


CHAPTER  XIII. 

HYPERCEMENTOSIS  AND  ARTIFICIAL  COMPLI- 

CATIOXS. 

Occasionally  tlie  root  of  a  tooth  is  all'octed  by  li ypercemeiitosis, 
an  excessive  development  of  the  tooth  cementuni.  The  enlarge- 
ment is  usually  at  the  ai)ex  of  the  root,  but  may  extend  from  the 
apex  to  the  neck  and  cover  the  entire  root.  No  specific  rule  can 
be  applied  for  the  removal  of  a  tooth  so  affected,  as  the  pro- 
cedure to  be  followed  will  depend  on  existing  conditions.  The 
technic  of  operation  described  for  such  cases  is  of  average  appli- 
cation, to  be  varied  according  to  peculiar  exigencies  that  may  be 
present.  Figure  183  shows  a  number  of  hypercementosed  teeth, 
and  attention  is  directed  to  the  great  variation  in  both  the 
amount  and  form  of  the  secondary  deposit  of  cementum. 

It  is  sometimes  necessary  to  extract  a  tooth  supporting  some 
form  of  crown  or  serving  as  an  abutment  for  a  lu^idge,  or  to 
remove  a  root  or  an  unerupted  tooth  situated  below  some  part 
of  a  bridge,  and  such  conditions  are  referred  to  as  artificial 
complications. 

Where  a  part  of  a  tooth  or  an  unerupted  tooth  below  a  bridge, 
a  crowned  tooth,  or  a  tooth  that  serves  as  an  abutment  for  a 
bridge,  is  to  be  extracted,  the  operator  should  devise  such  pro- 
cedure as  the  peculiar  conditions  may  indicate. 

HYPERCEMENTOSIS. 

Hypercementosis  of  the  roots  of  teeth  often  greatly  compli- 
cates their  extraction.  It  is  impossible  to  diagnose  hypercemen- 
tosis by  an  external  examination,  as  the  general  appearance  of  a 
tooth  does  not  give  any  evidence  of  this  condition,  and  the  dis- 
covery of  its  existence  after  the  operation  has  begun  is  often  a 
surprise  to  the  operator.  Resistance  to  the  operation  is  the 
first  indication  of  the  probability  of  its  ]U'esence,  Imt  undue 
resistance  should  not  l)e  relied  on  as  a  ])ositive  diagnosis  of  this 
condition,  as  abuoi-iiialities  to  which  any  tooth  is  subject  may 

323 


324  HYPERCEMENT08I8  AND  ARTIFICIAL  COMPLICATIONS 


Fig.  183. — Hypercementosis.     Types   of  hypercementosed  teeth,   showing  various   forms 
of  excessive  development   of  the  cementum. 


HYPERCEMENT08IS 


325 


also  cause  unexpected  resistance.  Hypercementosis  may  be  re- 
vealed by  a  radiograph,  but  even  the  radiograph  will  not  always 
definitely  outline  this  condition. 

A  radiograph  of  an  interesting  case  of  hypercementosis  of  the 
root  of  an  inferior  second  bicuspid  is  shown  in  Fig.  184.  This 
picture  was  not  obtained  for  the  purpose  of  diagnosing  the 
hypercementosed  condition,  but  to  ascertain  if  any  parts  of  the 
roots  of  the  first  molar  remained  in  the  intervening  space 
between  the  second  bicuspid  and  second  molar. 

Etiology. — Little  is  known  of  the  etiology  of  this  abnormal 
deposit  of  cementum.  It  is  most  frequently  found  on  the  roots 
of  teeth  that  are  in  malocclusion  and  isolated.  The  inferior 
bicuspids  and  second  molars  are  prone  to  this  condition,  but  it 
may  be  found  on  any  tooth  or  root  that  may  remain  in  the 


Fig.  184. — Radiograph  of  a  hypercementosed  inferior  second  bicuspid. 


mouth,  even  if  the  root  is  badly  broken  down  by  caries.  Occa- 
sionally, where  the  crown  of  a  tooth  has  been  destroyed  by 
caries  and  the  roots  are  left  in  position  in  the  arch  for  some 
time,  they  are  united  throughout  the  greater  part  of  their  length 
by  this  deposit.  It  may  cover  the  entire  root  rather  uniformly 
or  appear  in  irregular  deposits  on  any  part  of  a  root,  and  it  may 
be  found  only  on  one  root  of  a  tooth  or  on  all  of  them,  and  occurs 
on  one  or  a  number  of  teeth  in  a  mouth,  but  seldom  on  all  of 
them. 

Diagnosis. — Hypercementosis  may  be  suspected  by  the  oper- 
ator, in  the  absence  of  a  radiograph  or  where  the  condition  is 
not  shown  by  the  radiograph,  where  greater  resistance  is  en- 
countered during  the  extraction  than  the  diagnostic  conditions 
of  the  particular  tooth  and  its  attachment  would  seem  to  indi- 
cate, or  where  resistance  is  met  after  the  tooth  has  been  com- 


326  HYPERCEMENTOSIS  AND   ARTIFICIAL   COMPLICATIONS 

pletely  loosened  from  its  attachment,  but  cannot  be  released 
from  its  socket,  the  latter  complication,  when  occurring  with 
a  single-rooted  tooth,  being  possibly  the  most  certain  indication 
of  hypercementosis.  In  these  cases  the  apical  end  of  the  root 
is  enlarged,  and  presents  a  greater  diameter  than  the  orifice 
through  which  it  must  pass  in  its  exit  from  the  socket. 

Extraction  Technic — Anterior' 'Teeth. — Where  the  presence  of 
hypercementosis  on  the  root  or  roots  of  a  tooth  to  be  extracted 
has  been  diagnosed  by  a  radiogra]ih,  the  operation  for  its  re- 
moval will  depend  on  the  amount  of  surface  involved,  the  form 
which  the  secondary  cementum  has  taken,  and  largely  on  the 
particular  tooth  affected.  If  it  is  in  one  of  the  ten  superior  or 
inferior  anterior  teeth,  and  the  tooth  is  only  slightly  affected, 
the  procedure  should  be  the  same  as  where  this  condition  does 
not  exist.  If  the  affection  is  extensive,  involving  the  entire 
length  of  the  root,  oi'  if  only  the  apical  end  is  affected,  causing 
an  enlargement  of  the  end  of  the  root,  as  diagnosed  by  a  radio- 
graph or  by  a  failure  at  extraction,  enough  of  the  process  should 
be  cut  away  from  around  the  neck  of  the  tooth  to  allow  the 
forceps  to  be  firmly  adjusted  well  up  on  the  root,  when  the  ex- 
traction movements  are  made  with  the  object  of  dilating  the 
socket  sufficiently  to  permit  a  release  of  the  tooth.  If  by  this 
procedure  the  tooth  cannot  be  released  without  an  undue  appli- 
cation of  force,  or  there  is  reason  to  conclude  that  a  fracture  of 
the  alveolus  is  liable  to  occur,  it  is  advisal)le  to  release  the  tooth 
and  cut  away  the  outer  ])late  of  the  alveolar  process  sufficiently 
to  allow  the  root  to  pass  through  the  opening  thus  formed. 

Molar  Teeth. — Where  hypercementosis  exists  on  a  molar  tooth, 
only  a  faint  outline  of  its  presence  is  revealed  l)y  a  radiograph. 
Where  a  superior  or  an  inferior  molar  is  hypercementosed,  it  is 
preferable  to  first  attempt  to  extract  the  tooth  by  dilating  the 
socket,  and  then  bring  the  tooth  in  the  direction  of  the  weaker 
part  of  the  alveolus  surrounding  it,  applying  the  usual  extrac- 
tion movements.  In  such  case  the  application  of  the  maximum 
amount  of  force  is  permissible  with  the  tractile  movement,  but 
so  great  a  force  as  would  fracture  the  ])rocess  or  tooth  should 
not  be  applied.  If,  however,  a  fracture  of  the  tooth  occurs,  it 
will  usually  take  place  at  a  point  well  up  on  the  root  or  roots, 
and  the  removal  of  the  remaining  parts  will  be  an  extremely 
difficult  procedure.     If  the   tooth   cannot  be   released  by   the 


HYPERCEMENT0SI8  327 

method  described,  the  crown  should  be  fractured  by  exerting  a 
heavy  pressure  on  the  beaks  of  the  forceps  while  adjusted  to  the 
neck  of  the  tooth.  The  roots  of  the  tooth  are  then  separated  if 
the  fracture  has  not  already  caused  a  separation,  and  the  process 
is  carefully  removed  from  around  each  root  with  a  fissure  or  rose 
bur  sufficiently  to  allow  the  enlarged  root  to  pass  through  the 
space  created.  The  forceps  are  adjusted  for  the  extraction,  or 
the  Cryer  elevator  is  a|)plied  for  that  purpose  if  considered  more 
practicable. 

Inferior  Third  Molar. — Where  the  inferior  third  molar  is 
slightl.y  hypercementosed,  it  may  be  removed  by  dilating  the 
socket  as  described  for  the  molar  teeth,  but  undue  force  should 
not  be  api^lied  in  its  extraction,  for,  if  the  roots  are  small  and 
the  enlarged  condition  is  confined  to  the  apical  ends  of  the  roots, 
a  fracture  will  be  the  result,  ISTeither  should  the  crown  be  frac- 
tured with  the  forceps  preliminary  to  the  separation  and  re- 
moval of  the  roots  described  under  hypercementosed  molar  teeth 
(page  326),  as  the  roots  may  be  so  shaped  that  the  fracture  will 
occur  at  some  distance  below  the  crown.  If  the  condition  is  such 
that  the  tooth  cannot  be  extracted  by  the  method  just  described, 
or  by  a  removal  of  the  marginal  ridges  of  the  process  prelimi- 
nary to  the  application  of  the  forceps  or  elevator,  the  procedure 
should  be  the  :removal  of  the  lingual  plate,  as  described  in  the 
case  of  impacted  third  molar  (page  311). 

A  very  rare  case  of  hypercementosis,  with  a  peculiar  root  for- 
mation, is  reported  by  Professor  Vorslund-Kjaer,  a  dentist  of 
Copenhagen,  Denmark,  as  follows: 

"A  patient,  a  professor  of  medicine  in  Copenhagen,  presented 
himself  several  years  ago  at  my  office,  suffering  with  a  severe 
inflammation  in  the  right  mandil)le,  caused  l)y  a  third  molar. 
The  condition  was  such  that  he  could  only  i)artly  open  his 
mouth.  The  tooth  was  very  loose,  the  surrounding  tissue  was 
greatly  swollen,  and,  on  pressure,  pus  issued  al)uu(lantly  from 
the  socket.  Immediate  extraction  was  advised,  but  during  the 
extraction  I  felt  a  peculiar  sensation  as  if  the  tooth  were  held  by 
a  very  strong  band  at  the  apex  of  tlie  root.  The  extraction  was 
followed  by  a  most  severe  hemorrhage,  accom]ianied  by  excru- 
ciating pain,  from  which  the  patient  sultei-ed  terribly.  Tlie 
socket  was  carefully  packed  with  a  tami)on,  but  the  hemorrhage 
continued  for  a  considerable  time.     After  the  flow  of  l)lood  was 


328  HYPERCEMENTOSIS  AND  ARTIFICIAL  COMPLICATIONS 

finally  stopped,  the  patient  still  complained  of  severe  pain  along 
the  whole  course  of  the  trigeminus  nerve.  On  taking  a  glass  to 
his  lips  in  order  to  rinse  his  mouth,  he  exclaimed,  'What  is  the 
matter?     Is  the  glass  broken?     I  can  feel  only  half  of  it!' 

"The  extracted  tooth  was  of  very  unusual  shape.  The  layer 
of  pericementum  was  of  enormous  bulk,  presenting  almost  the 
appearance  of  a  single  osteophyte,  with  an  oval  hole  near  the 


Fig-.  185. — Lower   third   molar  with    foraminal  arrangement    of  roots,    due   to   hyper- 
cementosis,  causing  inclusion  of  mandibular  nerve  and  artery. 

apex  of  the  root  (Fig.  185).  Through  this  hole  the  nerve  and 
the  mandibular  artery  had  passed,  and  had  been  torn  asunder 
by  the  extraction,  which  accounted  for  the  excessive  hemor- 
rhage, the  intense  pain,  and  the  insensibility  of  the  right  half  of 
the  lip.  In  this  case  the  pain,  for  the  intensity  of  which  I  know 
but  a  single  parallel  in  dental  literature,  lasted  for  a  couple  of 
days,  but  the  insensibility  was  permanent.  It  was  fortunate  for 
me  that  the  patient  in  this  unparalleled  case  was  a  medical  man, 
who  thoroughl}^  understood  the  situation,  and  who,  up  to  this 
day,  speaks  of  his  experience  with  an  impersonal  interest." 

ARTIFICIAL  COMPLICATIONS. 

In  extracting  a  tooth  with  a  porcelain  crown,  especially  when 
operating  under  a  general  anesthetic,  care  must  be  exercised 
in  order  that  parts  of  the  crown  are  not  detached  and  pass  down 
the  throat  or  into  the  trachea,  for  porcelain  is  subject  to  fracture 
under  the  application  of  the  forceps.  The  same  precaution 
should  be  observed  in  removing  a  tooth  containing  an  inlay  or 
a  large  metal  filling. 

Extracting  a  Root  Supporting  a  Dowel  Crown. — Where  the 
root  of  a  tooth  supporting  a  dowel  crown  is  to  be  extracted,  a 
careful  examination  should  be  made,  as  stated  in  the  chapter  on 
examinations    (page  85),  by  passing  an  exploring  instrument 


ARTIFICIAL  COMPLICATIONS  329 

below  the  base  of  the  crown  and  where  it  comes  in  contact  with 
the  root,  as  the  root  may  be  destroyed  by  caries  at  this  point. 
If  the  root  is  not  so  affected,  the  forceps  are  applied  in  the  same 
manner  as  if  the  tooth  had  a  natural  crown;  but  the  crown 
should  not  be  relied  on  to  support  the  beaks  of  the  forceps  unless 
the  root  is  not  firmly  attached  to  the  tissues.  Where  the  root  is 
involved  by  caries,  the  beaks  of  the  forceps  are  sent  well  under 
the  free  margin  of  the  gum,  and,  if  necessary,  an  alveolar  appli- 
cation is  made  to  secure  a  firm  adjustment  on  the  root.  The 
extraction  movements  should  be  the  same  as  described  for 
operating  on  a  tooth  with  a  natural  crown.  If  the  artificial 
crown  is  fractured,  leaving  the  root  intact  and  the  dowel  is  in 
position  in  the  root,  the  root  possesses  increased  strength  and 
will  usually  bear  the  application  of  the  forceps,  the  liability  of  a 
fracture  in  such  case  being  less  than  when  extracting  a  root 
whose  crown  has  been  reduced  by  caries. 

Utilizing  a  Post  for  the  Extraction.— Occasionally  a  case  re- 
quiring extraction,  especially  with  the  six  superior  anterior  teeth, 
is  presented  where  the  root  has  supported  a  dowel  crown  and  the 
crown  has  fractured,  leaving  the  root  of  the  tooth  intact,  with 
the  post  projecting  and  firmly  cemented  in  the  root  canal.  In 
such  case  extraction  can  often  be  performed  by  applying  the 
beaks  of  Standard  forceps  No.  1  to  the  projecting  pin,  and,  with 
a  tractile  movement  executed  in  line  with  the  axis  of  the  root, 
extracting  it  in  the  same  manner  as  a  root  is  removed  with  the 
screw-porte  inserted  in  the  root  canal. 

Extracting  a  Tooth  Supporting  a  Shell  Crown. — Where  the 
tooth  to  be  extracted  is  supporting  a  shell  crown,  and  the  tooth 
is  not  firmly  attached  to  the  tissue,  but  the  crown  is  securely 
cemented  to  the  tooth,  the  forceps  can  often  be  applied  to  the 
crown  and  the  tooth  extracted  in  the  same  manner  as  if  the  tooth 
were  not  crowned,  but  a  minimum  amount  of  pressure  should  be 
exerted  on  the  crown  during  the  extraction. 

If  the  tooth  is  firmly  supported  by  the  tissue  and  the  crown  is 
securely  cemented  to  the  tooth,  too  much  reliance  should  not  be 
placed  on  the  crown  to  withstand  the  force  of  the  extraction 
movements,  as  frequently  roots  supporting  tlie  crown  are  built 
up  with  amalgam  or  cement,  and  the  pressure  of  the  beaks  of  the 
forceps  will  release  the  crown  from  its  abutment  and  fracture  the 
remainder  of  the  natural  crown.     In  most  of  these  cases  the  for- 


330  HYPERCEMENT0SI8  AND  ARTIFICIAL  COMPLICATIONS 

ceps  should  be  adjusted  well  under  the  free  margin  of  the  gum 
to  secure  a  firm  application  to  the  neck  of  the  tooth,  and,  this 
having  been  obtained,  the  presence  of  the  artificial  crown  is  dis- 
regarded and  the  tooth  extracted  by  the  operative  technic  pecu- 
liar to  its  removal. 

If  the  crown  is  loosely  attached,  or  caries  involves  the  gingival 
margin  of  the  tooth,  and  the  latter  is  firmly  supported  by  its  tis- 
sue, it  is  advisable  to  remove  the  crown  before  a]iplying  any 
instrument  to  extract  the  tooth,  as  the  crown  may  interfere  with 
the  procedure  and  cause  a  fracture  of  the  tooth. 

Extracting-  a  Bridge  Abutment. — Where  the  roots  of  teeth  that 
serve  as  abutments  for  a  l)ridge  are  to  be  extracted,  the  technic 
to  be  applied  for  their  removal  will  depend  on  the  size  and  loca- 
tion of  the  bridge,  the  stability  of  the  bridge  abutments,  and  the 
firmness  of  the  attachment  of  the  teeth  to  the  supporting  tissues. 
It  will,  of  course,  be  understood  that  if  only  one  abutment  is  to  be 
extracted,  the  bridge  should  be  removed  prior  to  the  extraction 
by  cutting  it  at  such  a  point  as  will  facilitate  its  removal  without 
injury  to  the  tooth  that  is  left  m  situ.  The  extraction  should  be 
made  by  the  method  described  for  the  same  tooth  when  not  serv- 
ing as  an  abutment,  observing  the  same  preliminary  procedure 
that  is  applicable  to  the  artificial  crown  of  which  the  abutment  is 
a  type. 

If  both  abutments  are  to  be  extracted,  and  they  are  firmly 
fixed,  the  forceps  should  be  applied  first  to  the  posterior  abut- 
ment, loosening  that  tooth,  and  then  applied  to  the  anterior  tooth, 
loosening  it  also,  when  a  tractile  movement  with  the  forceps  on 
one  of  the  teeth  will  usually  cause  both  teeth  to  leave  their 
sockets.  If,  however,  the  examination  indicates  that  both  teeth 
cannot  leave  their  sockets  at  the  same  time,  the  bridge  should  be 
severed  prior  to  the  extraction  at  a  point  that  will  best  facilitate 
the  operation. 

If  more  than  two  abutments  supporting  the  same  bridge  are  to 
be  extracted,  they  should  be  loosened  separately  as  described 
above,  after  which  the  forceps  are  applied  to  one  of  the  loosened 
abutments  and  the  extraction  movements  made  so  that  all  will 
leave  their  sockets  together,  making  the  final  extraction  move- 
ments as  near  as  possible  in  the  line  with  the  axes  of  the  roots. 
Where  the  teeth  are  so  situated  that  this  procedure  is  not  prac- 
ticable, it  will  be  necessary  to  cut  the  bridge  at  ditferent  points. 


ARTIFICIAL  COMPLICATIONS  331 

Extracting  a  Tooth  or  a  Root  Situated  Below  a  Bridge. — 

Where  a  bridge  is  firmly  cemented  to  one  or  more  abutments,  and 
a  root  or  partially  erupted  tooth  situated  below  some  part  of  the 
bridge  is  causing  a  pathologic  condition  that  requires  its  re- 
moval, the  disturbing  factor  should  be  extracted,  where  possible, 
without  removing  the  bridge.  If  a  case  of  this  character  occurs 
in  the  inferior  arch,  and  a  root  of  considerable  size  is  below  the 
bridge,  the  technic  described  for  using  the  hawksbill  forceps  for 
removing  a  tooth  wedged  between  two  adjacent  teeth  (page  216) 
can  sometimes  be  applied,  modifying  the  procedure  to  conform 
to  the  condition  presented.  Where  such  procedure  is  not  prac- 
ticable and  only  a  small  root  or  a  tooth  with  a  single  root  is  the 
cause  of  the  disturbance,  the  part  can  frequently  be  extracted  by 
incising  the  gum  tissue  over  it,  applying  the  elevator  at  the  most 
favorable  point  for  an  adjustment,  and  loosening  the  tooth  or 
root,  when  it  is  forced  from  its  position  in  the  direction  offering 
the  least  obstruction,  using  for  this  purpose  an  elevator,  mastoid 
chisel,  or  ordinary  enamel  chisel.  If  the  tooth  possesses  more 
than  one  root,  or  if  the  disturbing  element  is  an  unerupted  tooth, 
and  it  appears  that  the  extraction  would  endanger  the  bridge, 
the  bridge  should  be  removed  before  attempting  the  extraction. 


CHAPTER  XIV. 
ACCIDENTS. 

The  operator  should  acquaint  himself  with  the  features  of  such 
accidents  as  are  liable  to  occur  in  connection  with  the  extraction 
of  a  tooth,  and  become  familiar  with  the  best  methods  designed 
to  prevent  them.  Accidents  may  happen  quite  frequently  with 
a  beginner,  and  even  an  experienced  practitioner  is  not  exempt 
from  occasional  unfortunate  occurrences.  Every  precaution 
should  be  taken  to  prevent  an  accident,  but  so  many  contingen- 
cies are  liable  to  arise  during  extraction  operations  that  some- 
times an  accident  is  unavoidable.  If  an  accident  occurs,  the 
operator  should  maintain  his  equanimity  and  not  be  discon- 
certed, as  a  patient  is  usually  quick  to  notice  any  confusion  on 
the  part  of  the  operator  and  become  apprehensive  as  to  the  out- 
come of  the  operation.  In  most  cases  the  operation  should  be 
continued  as  if  the  accident  were  one  of  the  contingencies  that 
might  be  expected,  but  in  some  instances  an  explanation  will 
give  assurance  to  the  patient. 

FRACTURES  OF  THE  TEETH. 

Causes. — An  accidental  or  unavoidable  fracture  of  a  tooth  is 
the  most  common  accident  in  connection  with  the  operation  for 
its  extraction,  and  may  result  from  a  number  of  causes,  of  which 
the  following  are  mentioned: 

1.  Failure  to  make  a  thorough  preliminary  examination. 

2.  Lack  of  knowledge  of  the  anatomy  of  the  tooth  and  of  the 
tissues  by  which  it  is  retained. 

3.  Not  correctly  estimating  the  inherent  strength  of  the  tooth 
or  the  resistance  to  be  overcome  by  its  extraction. 

4.  Use  of  an  instrument  not  suited  to  the  tooth  to  be  extracted, 
either  because  the  proper  instrument  has  not  been  selected  for 
the  operation  or  the  instrument  is  not  correctly  constructed. 

5.  Misapplication  of  forceps  or  elevator. 

6.  Improper  execution  of  the  extraction  movements. 

7.  Closing  the  beaks  of  the  forceps  too  tightly  on  the  tooth. 

332 


FRACTURES  OF  TEETH  333 

8.  Attemj)ting  the  extraction  movements  too  soon,  or  before 
completing  the  application  of  the  instrument  to  the  tooth. 

9.  Operating  too  rapidly,  and  thereby  losing  the  sense  of  culti- 
vated touch. 

10.  Lack  of  perfect  control  of  the  instrument  throughout  the 
operation. 

11.  Interference  by  the  patient  during  the  operation,  either  in 
consequence  of  pain  or  from  any  other  cause. 

12.  Failure  to  properly  observe  the  space  through  which  the 
tooth  is  to  pass — e.  g.,  where  the  space  between  the  teeth  is  so 
narrow  that  it  is  impossible  to  pass  the  tooth  through  it  without 
fracturing  the  tooth  that  is  being  extracted  or  disturbing  an 
adjacent  tooth. 

13.  Failure  to  gauge  the  strength  of  the  tooth  where  extensive 
caries  has  weakened  the  parts. 

14.  Abnormality  of  tooth. 

15.  Abnormality  of  supporting  structures. 

Informing  Patient  of  Probable  Fracture. — Where,  on  examina- 
tion, conditions  indicate  that  a  fracture  may  occur  during  the 
operation,  and  a  local  anesthetic  is  to  be  employed,  it  is  advisable 
to  inform  the  patient  of  the  probability  of  such  fracture,  so  that, 
if  a  fracture  occurs,  the  patient  will  not  be  disposed  to  doubt  the 
ability  of  the  operator  and  will  permit  the  extraction  to  be  com- 
pleted without  hesitancy.  If  in  such  case  the  operator  neglects 
to  intimate  the  probability  of  a  fracture,  the  patient  may  not 
only  refuse  to  submit  to  further  procedure  at  the  same  sitting, 
but  may  be  inclined  not  to  return  for  the  completion  of  the  ex- 
traction. 

There  are  also  many  cases  presented  where  the  dentine  of 
the  crown  is  destroyed,  but  the  greater  portion  of  the  enamel 
walls  is  intact.  These  walls  possess  little  strength,  but  should 
not  be  removed  prior  to  the  extraction,  as  they  serve  as  an  ex- 
cellent guide  in  directing  the  beaks  of  the  forceps  to  a  correct 
position  on  the  roots,  although  they  will  usually  fracture  at  the 
beginning  of  the  extraction  movements.  The  patient  should  be 
informed  of  the  nature  of  the  crackmg  noise  that  will  probably 
occur  where  this  condition  is  presented,  for,  if  this  is  not  done, 
the  impression  will  be  that  the  tooth  is  fractured  and  will  likely 
result  in  a  sudden  interference  by  the  patient  at  the  most  critical 
time  of  the. operation. 


334  ACCIDENTS 

Resulting  Shock. — Where  a  fracture  has  occurred  in  an  at- 
tempted extraction  and  the  patient  is  not  under  a  general  anes- 
thetic, the  resulting  shock  is  often  more  severe  than  if  the  tooth 
had  been  extracted  in  its  entirety,  as  the  very  thing  that  was 
most  dreaded  has  actually  occurred.  If  the  shock  is  very  mild 
and  the  remaining  parts  are  accessible,  the  operation  can  usually 
be  completed,  but  the  judgment  of  the  operator  must  be  quick 
and  decisive.  If,  however,  the  shock  has  been  of  such  a  nature 
that  the  oj^eration  cannot  be  completed,  the  patient  is  permitted 
to  rest,  stimulants  are  administered  if  necessary,  and  a  glass  of 
sterilized  water  is  given  to  clear  the  mouth  of  any  blood  that  may 
be  present.  As  soon  as  practicable  the  parts  are  again  exam- 
ined, and,  if  the  procedure  is  of  a  simple  nature,  the  operation  is 
completed.  If  conditions  indicate  that  the  operation  to  follow 
will  necessarily  be  ])ainful  or  difficult,  it  is  advisable  to  admin- 
ister a  general  anesthetic,  as  the  patient  often  interferes  at  the 
moment  the  instrument  touches  the  parts  and  before  an  adjust- 
ment can  be  made.  Such  interference  delays  the  procedure, 
which  increases  the  nervous  tension,  and  frequently  repeated 
attempts  to  secure  an  adjustment  become  necessary,  or  the  tooth 
is  again  fractured  by  applying  the  extraction  movements  before 
a  correct  application  has  been  made  to  the  parts.  This  may  re- 
sult in  an  increased  shock,  and  so  aggravate  the  condition  that 
the  patient  will  not  submit  to  the  comj^letion  of  the  operation. 

Under  General  Anesthetic. — Where  a  fracture  occurs  when 
operating  under  a  general  anesthetic /ind  the  remaining  parts  are 
accessible,  the  operation  should  be  completed.  If  the  operator 
observes,  as  the  tooth  leaves  the  socket,  that  a  small  portion  of 
the  apical  end  of  the  root  is  left  in  situ,  he  must  quickly  deter- 
mine whether  he  shall  attempt  to  remove  the  remaining  part  be- 
fore allowing  the  patient  to  recover  from  the. anesthetic,  or  allow 
it  to  remain  temporarily  until  a  correct  diagnosis  of  the  part 
remaining  can  be  obtained.  In  the  majority  of  these  cases  the 
effort  to  complete  the  extraction,  especially  if  the  remaining 
part  is  very  small  and  the  alveolus  is  in  a  normal  state,  will  be 
made  in  an  uncertain  manner,  as  the  hemorrhage  soon  fills  the 
wound,  and  the  attempt  to  locate  the  unextracted  part  will  re- 
quire considerable  time,  or  will  result  in  the  tissue  being  lac- 
erated. It  is,  therefore,  occasionally  preferable  to  permit  the 
patient  to  recover  and  clear  up  the  wound,  after  which  the  re- 


FRACTURES  OF  TEETH  335 

maining  part  can  be  more  readily  located  and  extracted,  again 
administering  the  anesthetic  if  the  removal  of  the  fractured  part 
is  considered  a  difficult  operation. 

Sometimes  during  the  execution  of  the  extraction  movements, 
as  the  beaks  of  the  forceps  are  being  sent  over  the  neck  of  the 
tooth  with  the  required  amount  of  pressure,  the  operator  will  ex- 
perience a  sudden  delivery,  and  he  may  be  in  a  quandary  as  to 
whether  the  tooth  has  been  extracted  or  a  fracture  has  occurred 
at  its  neck.  In  such  case  he  must  quickly  ascertain  if  the  con- 
dition requires  a  continuation  of  the  extraction  procedure. 
Whether  the  tooth  or  part  released  remains  in  the  beaks,  drops 
on  the  tongue,  or  leaves  the  mouth,  an  examination  nmst  be  made 
at  once  to  learn  what  has  occurred;  if  it  leaves  the  mouth  and  is 
picked  up  by  the  assistant,  her  training  should  enable  her  to 
determine  whether  the  extraction  is  complete,  and  she  should 
inform  the  operator  accordingly.  Unless  the  operator  promptly 
learns  whether  the  extraction  is  complete,  an  attempt  may  be 
made  to  reapply  the  forceps  when  there  is  an  empty  socket,  or  he 
may  discontinue  the  operation  only  to  discover  some  time  after- 
ward that  a  fracture  has  occurred  and  the  remaining  part  is  left 
in  situ. 

Operative  Technic. — The  procedure  for  extracting  the  remain- 
ing part  of  a  tooth  in  case  of  fracture  is  described  for  each  tooth 
under  "Extraction  Technic"  (Chapters  IX,  X).  Precaution 
should,  however,  be  taken  in  all  cases  of  fracture  not  to  cause  any 
additional  complications  b\;  attempting  to  complete  the  extrac- 
tion while  operating  under  uncertainties,  and,  if  the  part  is  not 
accessible  to  the  intrument  that  is  being  employed,  repeated  at- 
tempts to  apply  the  instrument  should  not  be  made  in  an  effort 
to  force  the  issue,  for  in  many  instances  the  conditions  after  the 
fracture  vary  from  .those  first  presented,  and  should  be  treated 
as  an  entirely  different  case. 

Often  in  the  case  of  fracture,  when  repeated  application  of  the 
forceps  is  made  on  account  of  a  failure  to  deliver  the  remaining 
part,  the  alveolus  instead  of  the  tooth  will  be  grasped,  causing 
laceration  of  the  soft  tissue  and  repeated  fracture  of  the  tooth 
or  i)rocess  without  the  desired  result,  and,  in  addition,  giving  the 
patient  a  great  deal  of  pain.  Such  procedure  should  be  avoided, 
and  where  there  is  any  doubt  as  to  the  location  of  the  remaining 
part  the  area  around  the  structure  should  be  syringed  with  an 


336  ACCIDENTS 

antisej)tic  solution,  the  gum  tissue  retracted,  an  examination 
made  to  ascertain  tlie  amount  of  tooth  remaining,  and  a  method 
outlined  for  the  removal  of  the  part.  If  it  is  found  that  the  tooth 
is  deeply  seated,  and  that  the  alveolus  is  very  dense  and  protrud- 
ing beyond  the  tooth,  the  process  should  be  burred  away  to  allow 
a  secure  grasp  of  the  beaks  of  the  forceps  on  the  part  before  any 
further  atterai^t  is  made  to  extract  it.  If,  however,  the  forceps 
cannot  be  applied  for  extraction,  a  suitable  elevator  should  be 
adjusted  to  release  the  remaining  part  of  the  tooth. 

Hemorrhage. — Where,  in  the  case  of  a  fracture,  a  hemorrhage 
ensues,  it  is  usually  difficult  to  locate  the  unextracted  part,  as  the 
blood  from  the  wound  obscures  the  field  and  makes  a  reapplica- 
tion  of  the  instrument  of  extraction  uncertain.  If  the  tissue  is 
inflamed  and  there  is  continual  oozijig  of  blood  or  pus  from  the 
wound,  the  patient  should  be  allowed  to  rest  a  few  minutes,  after 
which  the  socket  is  syringed  with  an  antiseptic  solution  to  clear 
up  the  wound;  and,  if  this  does  not  have  the  desired  effect  and 
if  it  is  not  a  case  of  alveolitis,  an  application  of  a  styptic  or  of 
pressure  should  be  made. 

If  the  fractured  tooth  is  a  superior  first  bicuspid  or  one  of  the 
molars,  and  one  root  has  been  extracted,  the  empty  socket  may 
be  tightly  packed  with  gauze,  which  will  check  the  hemorrhage. 
The  gauze  dressing  may  be  left  in  place  until  the  completion  of 
the  operation,  when  it  is  removed. 

Cases  will,  however,  occur  where  the  oozing  of  blood  from  the 
socket  continues  in  spite  of  all  efforts  to  check  it,  and  it  is  de- 
sirable that  the  operation  be  completed  at  the  present  sitting. 
In  such  case  the  socket  is  filled  with  absorbent  cotton,  and  the 
operator,  holding  the  mouth  mirror  and  explorer  in  position, 
directs  the  assistant  to  quickly  remove  the  cotton  with  Derenberg 
tweezers,  when  the  parts  are  examined  before  the  blood  obscures 
its  location.  If  the  wound  fills  with  blood  before  the  inspection 
has  been  completed,  this  procedure  is  repeated  until  a  correct 
diagnosis  of  the  condition  of  the  remaining  part  of  the  tooth  is 
obtained.  If  the  condition  is  favorable  for  the  application  of 
forceps  or  elevator,  the  socket  is  again  filled  with  absorbent 
cotton,  and  the  operator,  holding  the  instrument  selected  for  the 
extraction  in  close  proximity  to  the  socket,  has  the  assistant 
quickly  remove  the  cotton  and  the  application  is  made  before 
blood  again  fills  the  wound. 


FRACTURE  OF  MAXILLARY  TUBEROSITY  337 


FRACTURE  OF  THE  ALVEOLAR  PROCESS. 

An  accidental  or  unavoidable  fracture  of  the  external  plate  of 
the  alveolar  process  may  occur  when  the  tooth  undergoing  ex- 
traction is  being  severed  from  its  attachment.  This  accident 
may  happen  when  every  precaution  has  been  taken  to  avoid  it 
and  the  extraction  has  been  correctly  performed,  but  serious 
consequences  seldom  follow  the  accident.  The  treatment  of 
such  conditions  is  described  under  "Treatment  After  Extrac- 
tion" (page  352). 

FRACTURE  OF  THE  MAXILLARY  TUBEROSITY. 

An  accidental  or  unavoidable  fracture  of  the  maxillary  tuber- 
osity may  occur  when  this  structure  is  prominent  and  too  great 
a  force  is  applied  against  it  during  the  extraction  of  a  superior 
third  molar.  This  accident  may  also  happen  if  the  forceps  are 
improperly  adjusted  and  the  beaks  seize  the  tuberosity  instead 
of  the  tooth. 

Great  care  should  be  taken  not  to  disturb  the  maxillary  tuber- 
osity when  extracting  a  superior  third  molar,  especially  if  the 
tooth  is  isolated,  extensively  decayed,  impacted,  or  its  roots 
hypercementosed  or  divergent.  The  same  degree  of  care  should 
be  exercised  when  extracting  a  superior  second  molar  where  the 
third  molar  is  missing  from  the  arch,  although  in  such  case  there 
is  less  liability  of  endangering  the  tuberosity. 

Injuries  incident  to  a  fracture  of  the  tuberosity  do  not,  as  a 
rule,  extend  beyond  that  eminence.  If  the  parts  are  not  en- 
tirely severed,  and  there  are  indications  that  a  union  will  again 
form,  the  wound  is  thoroughly  syringed  with  a  mild  antiseptic 
solution  to  remove  any  small  fractured  fragments  of  tooth 
or  process,  and  the  parts  are  readjusted  by  pressing  them  back 
to  their  normal  position.  A  light  dressing  of  gauze  is  then  in- 
serted in  the  open  wound  and  the  tuberosity  kept  as  immobile  as 
possible  for  several  days,  care  being  taken  to  prevent  infection 
by  frequent  and  liberal  use  of  a  nonirritating  antiseptic. 

If  the  parts  are  fractured,  being  either  carried  away  with  the 
tooth  or  are  so  loosely  attached  that  the  periosteum  is  entirely 
severed,  the  fractured  part  is  removed  by  holding  the  tuberosity 
with  Derenberg  tweezers  and  carefully  dissecting  the  soft  tissue 


338  ACCIDENTS 

from  it  with  a  lancet.  The  wound  is  then  carefully  syringed  and 
packed  with  a  light  gauze  dressing,  the  treatment  being  con- 
tinued daily  until  healthy  granulation  has  closed  the  wound. 

EXTRACTION  OF  AN  ADJACENT  TOOTH. 

The  accidental  extraction  of  a  wrong  tootli  may  occur  by  at- 
tempting to  operate  too  rapidly  and  consequently  misdirecting 
the  forceps  in  making  the  application.  An  accident  of  this  kind 
may  happen  also  where  the  field  of  operation  is  obscured  by 


Fig.  1S6. — Teeth  with  fused   roots.     Illustration  shows   various   forms  of  coalescence. 

blood  from  wounds  resulting  from  extraction  of  other  teeth  at 
the  same  sitting,  especially  when  operating  on  the  inferior  arch; 
or  where  the  case  is  of  a  complicated  nature,  and  the  operator 
endeavors  to  hurriedly  complete  the  operation  in  order  to  relieve 
the  patient  as  soon  as  possible. 

The  extraction  of  an  adjacent  tooth  may  also  occur  where  a 
tooth  is  fused  to  one  that  is  to  be  extracted,  as  it  is  seldom  possi- 
ble to  diagnose  this  condition  by  an  external  examination.  If 
such  a  fusion  is  suspected,  it  is  advisable  to  procure  a  radio- 
graph of  the  parts  to  satisfactorily  determine  the  prevailing 


FORCING  TOOTH  INTO  AB.'iCESS  CAVITY  339 

condition.  Conditions  of  this  character  (Fig.  186)  are,  however, 
very  rare,  and  accidents  caused  by  operating  too  rapidly  should 
not  occur,  and  will  not  happen  if  the  operator  will  not  let  his 
Sliced  of  operating  overcome  his  precision  in  the  application  of 
the  instruments  for  the  extraction,  and  will  always  ascertain  the 
location  of  the  parts  to  be  removed  when  in  doubt. 

In  case  of  an  extraction  of  an  adjacent  tooth,  it  should  be 
immediately  replanted  and  ligated  to  the  most  closely  approxi- 
mating teeth,  taking  the  precaution  to  previously  immerse  the 
tooth  in  a  weak  solution  of  lysol  to  render  it  antiseptic  if  it  has 
in  any  manner  come  in  contact  with  any  object  not  antiseptic. 
In  most  cases  the  tooth  will  again  become  attached  to  its  sup- 
porting tissue,  ])ut  the  case  should  be  under  careful  observation 
until  a  perfect  coalescence  is  formed. 

EXTRACTION  OF  OR  INJURY  TO  AN  UNERUPTED 

TOOTH. 

Extracting  or  injuring  an  unerupted  tooth  is  an  accident  that 
may  occur  when  extracting  a  deciduous  tooth  and  the  forceps 
are  applied  with  too  great  pressure,  the  beaks  being  directed 
beyond  the  deciduous  tooth,  and  both  permanent  and  deciduous 
teeth  are  seized. 

The  accidental  extraction  of  an  unerupted  tooth  is  unavoidable 
where,  in  extracting  a  deciduous  first  or  second  molar,  the  roots 
of  the  deciduous  tooth  are  firmly  attached  to  the  permanent 
bicuspid  and  both  leave  the  sockets  at  the  same  time.  Should 
such  an  accident  occur,  the  treatment  is  the  same  as  for  the 
extraction  of  an  adjacent  tooth,  described  above. 

FORCING  A  TOOTH  INTO  AN  ABSCESS  CAVITY. 

Where  an  abscess  area  of  considerable  size  exists,  the  tooth 
undergoing  extraction  may  be  accidentally  or  unavoidably  forced 
quite  a  distance  into  the  broken-down  tissue.  This  accident 
occurs  usually  in  the  region  of  the  superior  laterals,  first  bicus- 
pids, and  buccal  roots  of  the  molars,  and  in  the  region  of  the 
inferior  bicuspids  and  molars.  Where  a  root  or  tooth  that  ex- 
tends into  an  abscess  cavity  is  supported  by  partially  carious 
alveolar  structure,  which  also  supports  the  soft  tissue  over  it,  any 
pressure  of  the  forceps  on  the  part,  unless  it  is  firmly  held  by 


340  ACCIDENTS 

them,  will  often  send  it  quite  a  distance  into  the  cavity.  The 
same  kind  of  accident  may  occur  when  using  the  elevator,  espe- 
cially if  the  elevator  is  applied  with  too  great  a  force  and  not  in 
the  right  direction. 

Where  a  tooth  has  been  accidentally  forced  into  an  abscessed 
cavity,  the  wound  should  be  thoroughly  syringed  with  an  anti- 
septic solution  and  the  part  located.  By  applying  the  thumb 
and  index  finger  on  the  sides  of  the  wound  below  the  tooth,  the 
latter  may  often  be  forced  to  the  orifice.  If  the  tooth  cannot  be 
forced  from  the  cavity  by  this  method,  it  is  brought  to  the  sur- 
face with  an  elevator,  care  being  taken  not  to  apply  any  addi- 
tional pressure  on  the  tooth  while  engaging  it  with  the  elevator, 
as  that  would  tend  to  force  it  further  into  the  cavity  and  open  a 
larger  area  in  the  tissue  than  that  already  involved.  After  the 
removal  of  the  tooth  the  wound  should  be  treated  for  several 
days  as  described  for  like  conditions  under  "Chronic  Septic 
Pericementitis"  (page  365). 

FORCING  A  TOOTH  INTO  THE  MAXILLARY  SINUS. 

Accidentally  or  unavoidably  forcing  a  tooth  into  the  maxillary 
sinus  may  occur  when  operating  on  a  superior  second  bicuspid  or 
first  molar.  Occasionally  the  bony  structure  over  the  roots  of 
these  teeth  is  carious  to  such  an  extent  that  the  slightest  pressure 
with  an  instrument  will  cause  the  root  of  a  tooth  to  pass  into  the 
antral  cavity,  and  cases  are  on  record  where  the  entire  tooth  has 
been  pushed  into  this  cavity. 

In  removing  the  pulp  from  a  devitalized  tooth  the  broach  has 
been  known  to  pass  directly  into  the  antral  cavity,  and,  as  ab- 
scessed roots  often  communicate  directly  with  this  cavity,  forc- 
ing a  broken-down  root  into  the  antrum  is  an  accident  that  may 
occur  unavoidably  during  an  attempted  extraction,  as  the  con- 
dition of  the  structure  about  the  roots  cannot  be  previously 
determined. 

Where  a  tooth  or  the  root  of  a  tooth  has  been  forced  into  the 
maxillary  sinus,  the  socket  is  thoroughly  cleansed,  the  opening 
through  which  the  tooth  has  escaped  is  enlarged,  and  the  antrum 
is  flushed  with  tepid  water  or  a  mild  antiseptic  solution,  by  which 
procedure  the  part  may  be  flushed  out  of  the  sinus.  If  the  part 
does  not  come  out  with  the  flushing,  it  is  teased  over  the  opening 


FORCING  TOOTH  BETWEEN  TISSUES  341 

with  an  exploring'  instrument  or  Derenberg  tweezers;  or  a  loop 
of  wire,  attached  to  some  convenient  instrument,  is  inserted  in 
the  antrum,  and  the  tooth  caught  in  the  loop,  after  which  the 
loop  is  drawn  tight  and  the  tooth  brought  out.  The  socket 
and  antrum  are  again  flushed  with  a  mild  antiseptic,  and  then 
treated  with  antiseptic  and  stimulating  remedies  until  the 
wound  has  healed.  If  this  treatment  does  not  etfect  a  cure,  some 
antral  complication  that  requires  surgical  interference  is  usually 
present. 

FORCING  A  TOOTH  BETWEEN  THE  TISSUES. 

Forcing  a  tooth  between  the  soft  tissues  and  alveolus  may 
occur  when  operating  on  the  inferior  third  molar  where  there  has 
been  a  breaking  down  of  the  tissues  caused  by  extensive  suppura- 
tion or  otherwise.  Where  such  a  condition  exists,  it  is  advisable 
to  operate  very  cautiously  in  order  to  avoid,  if  possible,  the 
occurrence  of  such  an  accident.  The  case  usually  requires  the 
use  of  an  elevator  to  assist  in  releasing  the  tooth,  and  the  opera- 
tor, after  having  loosened  the  tooth  with  that  instrument  and 
in  attempting  to  apply  the  forceps  to  complete  the  extraction, 
discovers  that  the  tooth  is  missing  from  its  socket.  In  such  case 
an  examination  may  disclose  the  fact  that  the  tooth  has  left  its 
socket  and  passed  between  the  soft  tissues  and  the  alveolar 
process.  When  this  occurs,  the  tooth  should  be  located  at  once, 
and,  with  the  index  finger  placed  below  the  tooth,  it  is  carefully, 
but  firmly,  pressed  to  the  orifice  of  the  socket.  As  soon  as  the 
tooth  reaches  this  point,  it  is  grasped  with  Derenberg  tweezers 
or  forceps  and  carefully  withdrawn  from  the  mouth.  If  the 
tooth  cannot  be  brought  to  the  surface  in  the  manner  described, 
an  incision  is  made  at  the  most  suitable  point  for  the  delivery  of 
the  tooth  and  it  is  released  through  the  opening,  a  procedure  that 
should  be  avoided  where  possible,  but  one  that  becomes  neces- 
sary when  the  tooth  cannot  be  forced  back  over  the  course  it  has 
traversed.  After  the  tooth  has  been  removed,  the  wound  should 
be  thoroughly  syringed  with  an  antiseptic  solution,  and,  if  the 
wound  is  large,  it  should  be  sutured,  so  that  the  flaps  are  held 
together.  A  gauze  dressing  is  applied,  a  mouth  wash  pre- 
scribed, and  the  parts  treated  with  stimulating  antiseptics  until 
healthy  granulation  is  established. 


342  ACCIDENTS 

LOOSENING  AN  ADJACENT  TOOTH. 

If  an  adjacent  tooth  is  loosened  during  an  extraction,  it  should 
be  pressed  back  into  position  by  pressure  applied  with  the  thumb 
to  its  occlusal  surface;  and  if,  after  this  has  been  done,  it  is  found 
that  the  tooth  remains  elongated,  a  layer  of  cotton  is  placed  on 
the  occlusal  surface  and  the  patient  directed  to  forcibly  close  the 
teeth,  which  will  force  the  tooth  l)ack  to  its  normal  position.  If 
the  tooth  is  too  loose  to  remain  in  position  unsupported,  it  should 
be  ligated  to  the  adjacent  teeth  until  it  has  again  become  firmly 
attached  to  the  tissues. 

DISTURBING  ARTIFICIAL  RESTORATIONS. 

Cases  will  occur  where  a  filling  in  an  adjacent  tooth  will  l)e 
accidentally  or  unavoidably  disturbed  during  an  extraction  by 
the  application  of  the  forceps  or  elevator.  If  during  the  exami- 
nation the  operator  observes  that  such  an  accident  is  liable  to 
occur,  it  is  advisable  to  inform  the  patient  that  the  filling  may  be 
loosened  or  come  out  during  the  operation,  but  that  disturbing 
the  filling  will  not  cause  the  loss  of  the  tooth.  If  this  precau- 
tion is  not  taken  and  such  an  accident  occurs,  the  patient  may 
be  disposed  to  charge  the  operator  with  carelessness,  if  nothing 
worse.  The  disturbance  of  a  filling  is  usually  preferable  to  the 
fracture  of  the  tooth  to  be  extracted  where  it  is  necessary  to 
choose  between  the  two. 

A  porcelain  crown  may  be  accidentally  fractured  when  the  in- 
strument used  in  the  extraction  comes  in  violent  contact  with  the 
crown,  and  the  accident  may  also  occur  where  a  wooden  wedge 
or  mouth-gag  is  inadvertently  placed  on  such  a  crown.  In  all 
operations  for  the  extraction  of  a  tooth,  no  instrument  should 
be  permitted  to  come  in  contact  with  any  porcelain  restoration 
if  it  can  possibly  be  avoided. 

Occasionally  the  band  of  an  artificial  crown  extends  over  a 
part  of  a  tooth  or  a  root  to  be  extracted.  This  may  be  due  to  an 
improperly  fitting  band,  to  a  tooth  erupting  against  another 
tooth  and  the  crown  of  the  erupting  tooth  engaging  the  artificial 
band,  or  to  a  partial  destruction  by  caries  of  the  crowned  tooth 
and  the  approximating  tooth  occupying  the  space  created  by  the 
decay.  Where  possible,  in  such  condition,  the  part  should  be 
extracted  without  disturbing  the  crown,  but,  if  such  an  accident 


BRUISING  THE  LIP  343 

is  liable  to  occur,  the  operator  should  not  hesitate  to  protect 
himself  by  informing  the  patient  of  the  probable  result  of  the 
operation. 

DISTURBING  A  TREATMENT  IN  AN  ADJACENT  TOOTH. 

Where  a  tooth  adjacent  to  the  one  to  be  extracted  contains  a 
treatment,  retained  by  cotton,  cement,  or  other  means,  the  con- 
dition of  the  treatment  should  be  carefully  noted  before  the 
extraction,  and  care  be  taken  not  to  disturb  it  during  the  ex- 
traction, especially  if  it  is  an  arsenical  treatment.  If  the  re- 
taining medium  is  disturlied,  steps  should  be  at  once  taken  to 
prevent  any  of  the  medicinal  agent  entering  the  socket  of  the 
extracted  tooth,  and,  if  any  of  the  agent  enters  the  socket,  it 
must  be  removed  and  the  tissues  thoroughly  cleansed. 

A  case  of  this  nature  came  to  the  knowledge  of  the  author. 
An  inferior  second  molar,  containing  a  treatment  that  had  been 
previously  applied  by  another  operator,  was  used  as  a  fulcrum 
for  the  extraction  of  an  inferior  third  molar.  During  the  extrac- 
tion the  treatment  was  disturbed  without  being  observed,  and 
the  patient  was  dismissed.  Subsequently  a  decided  case  of 
arsenical  necrosis  developed,  Init  the  true  nature  of  the  condition 
was  not  learned  until  after  every  available  remedy  had  been 
tried  and  the  history  of  the  second  molar  was  obtained,  which 
disclosed  that  the  tooth  previously  contained  a  treatment  of  an 
arsenical  compound. 

BREAKING  AN  INSTRUMENT.       . 

The  breaking  of  a  beak  of  the  forceps  or  the  blade  of  an  eleva- 
tor during  the  extraction  movements  is  an  accident  that  occa- 
sionally occurs,  and,  when  it  does  occur,  the  broken  part  should 
be  removed  at  once.  No  operator  should  ever  court  an  accident 
of  this  kind  by  using  an  instrument  of  inferior  material  or  im- 
proper construction.  Instruments  that  must  undergo  the  tests 
to  which  forceps  and  elevators  in  practical  use  are  frequently 
subjected  cannot  possibly  be  too  well  constructed. 

BRUISING  THE  LIP. 

The  accidental  bruising  of  the  lip  may  occur  where  the  mouth 
is  small,  or  where  there  is  false  ankylosis;  or  where  the  extrac- 
tion is,  for  some  reason,  of  a  complicated  nature;  or  where  the 


344  ACCIDENTS 

patient,  from  nervousness  or  pain,  interferes  with  the  operator 
or  suddenly  closes  the  mouth.  The  accident  may  also  occur 
where  the  patient,  under  a  general  anesthetic,  disarranges  the 
mouth-prop,  making  it  necessary  to  use  a  mouth-gag  or  wooden 
wedge,  and  either  of  these  instruments  is  not  carefully  inserted 
and  impinges  on  the  lip. 

A  root  or  tooth  with  very  sharp  edges  should  be  carefully  re- 
moved from  the  mouth  after  being  detached  from  its  socket,  and 
should  not  be  allowed  to  touch  the  lips,  as  laceration  and  infec- 
tion may  follow  if  contact  occurs.  A  practicable  method  for 
protecting  the  lip  in  a  case  where  it  is  liable  to  be  bruised  is  to 
have  the  assistant  hold  a  towel  or  napkin  over  the  lip  of  the 
patient  to  protect  it  from  the  pressure  of  the  forceps.  If  the  lip 
is  bruised,  the  injury  is  immediately  noticeable,  as  the  parts 
quickly  become  swollen  and  discolor.  When  the  accident  occurs, 
an  ointment  should  be  applied  and  the  patient  instructed  to  keep 
the  parts  protected;  if  the  lip  is  cut,  the  parts  should  be  com- 
pressed to  check  any  hemorrhage,  and  an  antiseptic  dressing- 
applied. 

BRUISING  THE  CHEEK. 

The  lateral  walls  of  the  mouth  may  be  accidentally  wounded 
when  the  joints  of  the  forceps,  in  consequence  of  not  having  been 
rounded,  catch  these  tissues.  This  accident  can,  however,  be 
avoided  by  having  the  joints  of  the  forceps  rounded,  as  described 
on  page  9.  The  tissues  of  the  cheek  may  also  be  wounded  where 
the  instrument  used  for  extraction  slips  from  its  adjustment  on 
the  tooth  during  the  application  of  the  extraction  movements. 
If  any  partly  detached  tissue  results  from  either  of  these  acci- 
dents, it  should  be  trimmed  away,  the  wound  touched  with  tinc- 
ture of  iodin,  and  a  nonirritating  antiseptic  mouth  wash  pre- 
scribed. The  parts  usually  heal  without  causing  any  further 
trouble. 

WOUNDING  THE  TONGUE. 

Wounding  the  tongue  or  floor  of  the  mouth  is  an  accident  that 
may  occur  when  extracting  an  inferior  tooth  and  the  instrument 
is  not  securely  adjusted,  especially  when  the  tooth  is  out  of 
alignment  and  directed  toward  the  tongue,  or  it  may  happen 
through  carelessness  or  hasty  operating.     This  accident  is  par- 


DISLOCATION  OF  MANDIBLE  345 

ticiilarly  liable  to  occur  when  the  patient  is  under  a  general  anes- 
thetic and  the  forceps  are  inaccurately  applied  to  an  inferior 
tooth  that  is  obscured  by  blood  from  freshly  opened  sockets,  and 
involuntary  movements  of  the  patient  while  under  the  anesthetic 
may  also  cause  the  forceps  to  be  misdirected. 

If  the  wound  to  the  tongue  is  an  abrasion  or  a  laceration  that 
involves  only  the  surface,  any  partially  detached  tissue  is  then 
trimmed  away  and  a  mouth  wash  prescribed;  if  the  wound  is 
more  serious,  the  parts  should  be  thoroughly  cleansed,  the  hem- 
orrhage checked  by  compression,  tincture  of  iodin  applied  to  the 
wound,  and  an  antiseptic  mouth  wash  prescribed;  and  if  the  in- 
jury is  extensive,  the  tongue  should  be  drawn  forward  and  the 
injured  parts  ligated  with  catgut  before  applying  the  above 
treatment.  If  the  lingual  artery  is  severed,  it  should  be  com- 
pressed with  artery  forceps,  and  treatment  should  be  continued 
until  recovery  is  complete. 

DISLOCATION  OF  THE  MANDIBLE. 

Dislocation  of  the  lower  jaw  is  more  liable  to  occur  with  young 
women  of  delicate  physique,  and  may  happen  during  extraction 
when  the  jaws  are  fully  distended  and  excessive  pressure  with 
the  forceps  is  applied  without  the  chin  being  supported,  and 
when  the  mouth  is  forcibly  opened  with  a  gag. 

The  dislocation  is  usually  forward  of  the  normal  position,  with 
the  condyle  partially  slipped  out  of  the  glenoid  fossa  anteriorly 
toward  the  interarticular  cartilage,  and  may  be  bilateral  or  uni- 
lateral, the  former  being  the  most  common.  In  bilateral  disloca- 
tion the  mouth  cannot  be  closed,  the  inferior  teeth  protrude  be- 
yond the  superior  teeth,  the  face  appears  long  and  the  chin 
distended,  saliva  flows  from  the  mouth,  and  the  pain  is  usually 
moderate,  but  the  patient  swallows  and  talks  with  difficulty. 
In  unilateral  dislocation  the  mouth  is  not  open  so  far,  and  the 
jaw  is  displaced  toward  the  nondislocated  side. 

Treatment. — The  patient's  head  is  placed  comfortably  in  the 
head-rest  of  the  operating  chair.  The  operator,  having  wrapped 
his  thumbs  with  gauze,  takes  a  position  in  front  of  the  patient, 
and  places  his  thumbs  on  the  inferior  molar  teeth,  applying 
pressure  downward  and  backward.  The  fingers  that  are  free  are 
used  to  support  the  jaw  during  the  application  of  the  pressure, 
and  to  raise  the  chin  when  the  condvles  are  loosened.     If  this 


346  ACCIDENTS 

procedure  fails  to  reduce  the  dislocation,  a  mouth-prop  is  placed 
between  the  molar  teeth  and  pressure  is  applied  under  the  chin. 
In  unilateral  dislocation  the  pressure  with  the  thumbs  is  applied 
only  on  the  dislocated  side.  After  the  reduction,  if  no  difficulty 
has  been  encountered,  the  parts  seldom  give  further  trouble.  If, 
however,  the  muscles  or  coronoid  process  has  been  aifected,  a 
bandage  is  properly  applied,  and  the  patient  is  placed  on  a 
liquid  diet,  being  instructed  to  return  for  treatment  until  the 
inflammation  has  sufficiently  subsided  to  permit  the  removal  of 
the  bandage. 

FRACTURE  OF  THE  JAW. 

The  treatment  of  a  fracture  of  either  maxilla  from  some  trau- 
matic injury  does  not  come  within  the  province  of  the  exodontist, 
and  reference  is  made  to  it  here  only  as  a  possible  contingency 
that  may  arise  during  an  operation.  Fracture  of  the  jaw  during 
extraction  is  very  uncommon,  but  such  accidents  have  occurred. 
Precaution  should  always  be  taken  to  avoid  an  accident  of 
this  character,  especially  where  a  previous  fracture  occurred 
from  an  injury,  or  where  a  pathologic  condition  involving  the 
alveolus  and  maxilla  has  weakened  these  structures,  or  where 
their  normal  strength  has  been  reduced  by  a  surgical  opera- 
tion, or  where  they  are  weak  from  a  congenital  defect.  Where 
more  than  ordinary  resistance  is  encountered  during  the  extrac- 
tion movements,  it  is  advisable  not  to  attempt  to  overcome  it  by 
applying  extreme  force,  as  conditions  may  exist  that  militate 
against  a  forcible  extraction.  In  such  case  a  careful  examina- 
tion is  to  be  made,  and  any  interfering  obstruction  should  be 
removed  or  treated  in  such  manner  as  to  allow  a  delivery  of 
the  tooth. 

Symptoms. — In  case  of  fracture  the  symptoms  are  rapid  swell- 
ing of  tissue  over  the  fracture,  hemorrhage  over  the  lacerated 
parts,  saliva  flowing  freely  from  the  mouth,  unnatural  mobility, 
and  crepitus. 

Treatment. — The  fractured  parts  are  carefully  adjusted  so 
that  the  teeth  are  in  their  normal  occlusion,  hemorrhage  is 
checked,  and  the  wound  is  rendered  aseptic.  Fracture  bands  or 
some  form  of  splints  is  then  adjusted  to  immobilize  the  parts,  a 
mouth  wash  is  prescribed,  and  the  patient  placed  on  a  liquid  diet. 
The  parts  should  coalesce  in  about  four  weeks. 


TOOTH  PASSING  BEYOND  PHARYNX  347 


TEETH  LOOSENED  OR  DISPLACED  BY  ACCIDENT. 

Cases  are  presented  for  extraction  where  teeth  are  loosened  or 
driven  from  their  position  by  accident.  Such  teeth  should  sel- 
dom be  removed,  but  should  be  carefully  placed  in  position  and 
the  wound  treated,  and,  where  necessary,  they  should  l^e  retained 
by  suitable  splints.  If  the  operator  is  not  in  a  position  to  con- 
struct suitable  retaining-  appliances,  the  case  is  referred  to  a  com- 
petent general  dental  practitioner  for  this  purpose.  An  accident 
of  this  nature  occurs  more  frequently  with  the  superior  central 
incisors,  and  these  teeth,  when  such  an  injury  happens  by  a  fall 
of  the  i^atient  or  otherwise,  are  driven  far  into  the  soft  tissue 
and  alveolar  process.  In  such  a  case  a  proper  effort  should  be 
made  to  replace  the  teeth  and  retain  them  in  normal  alignment, 
but  a  careful  examination,  particularly  observing  the  amount  of 
alveolar  structure  that  may  be  involved,  should  be  made  before 
any  of  the  parts  are  treated.  If  the  alveolus  is  destroyed  to  such 
an  extent  that  the  teeth  can  no  longer  be  retained  by  this  struc- 
ture, they  should  be  removed,  preserving  every  tooth  that  can 
be  retained  and  as  much  as  possible  of  the  process. 

TOOTH  PASSING  BEYOND  THE  PHARYNX. 

Such  an  accident  may  occur  where  the  tooth  slips  from  the 
forceps,  or  where  the  elevator  is  used  and  the  operator  loses  con- 
trol of  the  tooth.  In  case  a  tooth  is  swallowed,  it  readily  passes 
through  the  alimentary  canal.  If,  however,  a  tooth  enters  the 
air  passages,  tracheotomy  may  necessarily  have  to  be  performed 
to  prevent  death. 


CHAPTER  XV. 
TREATMENT  AFTER  EXTRACTION. 

The  extraction  of  any  tooth  necessarily  creates  a  wound,  and 
every  such  wound,  no  matter  how  small,  is  a  more  or  less  fertile 
field  for  the  propagation  of  pathogenic  bacteria  and  a  gateway 
for  their  entrance  into  the  human  system.  This  condition 
should,  of  itself,  be  sufficient  reason  for  treatment  after  extrac- 
tion, as  an  open  wound  of  the  character  caused  by  the  removal  of 
a  tooth  from  its  supporting  structures,  however  simple  the  case 
may  be,  would  be  considered  serious  if  located  on  the  external 
surface  of  the  body,  and  no  surgeon  would  cause  a  wound  of  a 
similar  nature  without  due  attention  to  sepsis. 

Albuminous  substances  in  a  greater  or  jess  quantity  are  always 
present  in  the  mouth,  and  their  decomjiosition  by  the  action  of 
saprophytic  fungi  creates  derivatives  of/albumin,  many  of  which 
are  toxic  in  effect.  These  substances,  combined  with  pathogenic 
bacteria  that  are  so  often  present  even  in  a  healthy  mouth,  and 
all  of  which  are  held  in  suspension  by  the  saliva,  render  it  a 
highly  infectious  fluid,  and  thus  expose  to  contamination  from 
these  substances  any  abrasion  that  may  be  present  in  the  oral 
cavity.  If  wounds  existing  in  mouths  that  are  kept  in  a  state  of 
cleanliness  are  thus  exjDosed  to  infection,  the  degree  of  exposure 
in  the  average  mouth  must  b.e  much  greater.  Nearly  every  case 
of  extraction  is  an  infective  lesion  when  presented,  and  in  many 
cases  there  are  infected  lesions  in  other  parts  of  the  mouth. 
Unclean  teeth  and  marginal  gingivitis  are  the  rule  rather  than 
the  exception.  Pyorrhea  alveolaris,  sending  forth  its  daily 
supply  of  pus  from  numerous  pockets,  and  frequently  a  sinus 
discharging  toxins  at  irregular  intervals,  not  to  mention  the  in- 
fective pathologic  conditions  so  often  associated  with  the  tooth 
to  be  extracted,  are  conditions  only  too  often  presented.  Many 
forms  of  bacteria  that  cause  specific  diseases  are  frequently 
found  in  the  mouth,  among  which  is  the  pneumococcus,  or  bac- 
terium pneumoniae,  and  the  serious  nature  of  a  wound  infected 
by  this  organism  should  be  fully  realized. 

348 


EXTRACTION  WITHOUT  COMPLICATIONS  349 

In  view  of  the  many  sources  of  infection  to  which  a  wound 
caused  by  an  extraction  may  be  subject,  not  all  of  which  have 
been  mentioned,  and  the  fact  that  the  location  of  the  wound 
makes  it  impossible  to  maintain  a  perfect  aseptic  condition  at  all 
times  during  the  healing  process,  the  operator  should  not  fail  to 
adopt  the  necessary  measures  to  properly  treat  such  wound. 

EXAMINATION. 

Immediately  after  the  operation  the  extracted  tooth  is  exam- 
ined to  ascertain  if  it  is  intact,  if  a  fracture  has  occurred,  or  if 
any  gum  tissue  or  alveolar  process  is  attached  to  it,  and  any 
abnormalities  of  the  root  are  noted. 

The  gum  tissue  is  examined  for  any  injuries  that  may  have 
been  caused  by  the  application  of  the  instrument,  or  that  are  the 
result  of  any  difficulty  that  may  have  been  encountered  during 
extraction. 

The  margin,  septum,  and  cortical  plates  of  the  alveolar  process 
are  examined  for  any  injury  that  may  have  been  caused  by  the 
removal  of  the  tooth,  and  search  is  made  in  the  socket  if  it  is 
probable  that  any  foreign  body  has  entered  the  wound. 

The  adjacent  teeth  are  examined  to  determine  if  any  injury  has 
occurred  to  their  crowns,  if  their  attachments  have  been  dis- 
turbed, or  if  the  surface  of  any  tooth  that  may  be  extensively 
decayed  has  been  fractured  by  the  extraction,  leaving  sharp 
edges  that  will  irritate  the  cheek  or  tongue.  If  the  filling  of  an 
adjacent  tooth  is  loosened  or  has  come  out,  the  patient  should  be 
advised  of  the  fact. 

The  surrounding  tissues  are  carefully  examined,  and  any 
pathologic  condition  of  the  supporting  structures  is  noted  to 
determine  the  nature  and  extent  of  the  involvement. 

EXTRACTION  WITHOUT  COMPLICATIONS. 

Where  the  patient  is  not  afflicted  with  any  systemic  disturb- 
ances, where  the  oral  cavity  is  in  a  prophylactic  condition,  and 
where  there  are  no  pathologic  conditions  involving  any  of  its 
parts,  except  the  crowns  of  the  teeth,  the  field  of  operation  for 
the  removal  of  a  tooth  is  as  good  as  can  be  presented.  In  such 
case,  if  the  extraction  has  been  a  comparatively  simple  operation 
— the  tooth  having  been  readily  released  from  its  supporting 


350  TREATMENT  AFTER  EXTRACTION 

tissue  and  the  tissue  is  in  a  healthy  state — and  no  injury  has 
occurred  to  the  associated  parts,  save  the  contusion  of  the  gum 
tissue  and  rupture  of  the  peridental  membrane  necessarily 
caused  by  the  separation  of  the  tooth  from  its  attachment,  the 
extraction  is  one  without  complication,  and  the  treatment  to  be 
followed  is  of  the  simplest  nature. 

Treatment. — The  margins  of  the  socket  are  flushed  with  an 
antiseptic  solution  to  insure  the  removal  of  any  debris  that  may 
have  entered  from  around  the  neck  of  the  tooth,  and  that  could 
not  be  reached  when  these  parts  were  cleansed  preliminary  to 
operating.  The  primary  hemorrhage  following  the  extraction 
usually  ceases  in  a  few  minutes,  and  in  the  interim  the  patient  is 
given  a  glass  of  sterilized  water  with  which  to  clear  the  mouth 
of  blood,  but  the  water  should  not  be  used  too  freely.  Any  suc- 
tion of  the  wound  should  be  discouraged,  and  the  patient  should 
not  be  dismissed  until  the  hemorrhage  has  subsided.  (See 
Hemorrhage,  page  371.) 

The  blood  is  permitted  to  coagulate  in  the  socket,  and  the  clot 
should  not  be  disturbed,  as  it  is  impossible  to  apply  any  dress- 
ing that  will  protect  the  wound  with  the  same  efficacy  that  is 
afforded  by  the  clot.  The  patient  is  instructed  not  to  interfere 
with  the  clot  by  inserting  the  finger  into  the  wound  or  by  trying 
to  apply  a  dressing  of  any  kind.  An  antiseptic  mouth  wash  is 
prescribed,  which  should  be  used  freely  and  often.  The  frequent 
use  of  a  mild,  nonirritating  wash  is  preferred  to  the  occasional 
use  of  a  stronger  one  that  is  irritating,  as  by  a  liberal  use  of  the 
former  all  parts  of  the  mouth  can  be  cleansed  and  a  better  condi- 
tion of  asepsis  maintained.  As  to  choice  of  mouth  washes,  there 
is  probably  nothing  better  than  a  saturated  solution  of  boric 
acid  in  water,  or  the  Thiersch  solution  (salycilic  acid,  15  grains; 
boric  acid,  90  grains;  distilled  water,  recently  boiled,  16  ounces), 
which  is  very  efficacious.  There  are  a  number  of  proprietary 
mouth  washes  that  are  good,  and,  when  desirable,  the  one  most 
agreeable  to  the  patient  may  be  prescribed. 

The  patient  should  be  instructed  to  return  in  case  there  is  in- 
creased pain  or  swelling  of  the  parts  after  a  lapse  of  thirty-six 
to  forty-eight  hours  from  the  time  of  operating.  Usually  the 
cases  that  are  treated  in  the  manner  indicated  cause  no  further 
trouble,  but  proper  precaution  should  always  be  exercised  in 
order  to  prevent  possible  infection. 


TRAUMATIC  INJURY  TO  GUM  TI8SUE  351 

TRAUMATIC  INJURY  TO  THE  GUM  TISSUE. 

The  gum  tissue  in  the  immediate  region  of  the  extracted  tootli 
is  often  accidentally  or  unavoidably  injured.  Such  an  injury  is 
not,  as  a  rule,  of  an  extensive  nature,  and  is  usually  confined  to 
the  gingival  margin  and  the  septal  tissue  on  either  side  of  the 
tooth.  Occasionally  the  injury  extends  beyond  the  margins  of 
the  socket,  and  there  may  be  considerable  laceration,  or  the  loos- 
ening of  quite  an  area  of  gum  tissue  from  the  alveolar  process. 
Immediate  attention  given  an  injury  to  the  gum  tissue  in  such 
case  will  tend  to  reduce  the  liability  of  the  wound  becoming 
complicated. 

Treatment. — Where  the  injury  is  confined  to  a  contusion  of 
the  parts  or  the  carrying  away  of  a  small  amount  of  marginal  or 
septal  gum  tissue,  the  treatment  is  the  same  as  that  given  under 
"Extraction  Without  Complications"  (page  349).  Where  there 
is  laceration,  leaving  rough  edges  or  small  flaps  of  tissue  in 
which  the  circulation  will  likely  be  arrested,  the  ragged  parts 
should  be  removed  with  a  pair  of  curved  scissors ;  but  where  any 
considerable  area  of  tissue  has  been  loosened,  it  should  be  re- 
tained, if  possible,  in  order  to  protect  the  alveolar  process.  The 
detached  margins  are  carefully  adjusted,  and  will  usually  remain 
in  position  without  further  support;  but  where  the  process  does 
not  afford  the  proper  support,  the  parts  can  often  be  held  in 
place  by  inserting  a  cone  of  sterilized  gauze  in  the  socket.  The 
gauze  is  inserted  very  lightly,  so  as  to  allow  the  blood  clot  to  fill 
as  much  as  possible  of  the  socket,  and  should  be  removed  the  fol- 
lowing day,  when  the  margins  will  usually  remain  in  position 
without  further  support.  Where,  in  case  of  extensive  laceration 
or  where  the  gum  tissue  has  been  loosened  from  the  process,  the 
parts  cannot  be  retained  in  normal  position  by  means  of  the 
gauze  dressing,  they  should  be  retained  by  sutures.  A  mouth 
wash  (page  350)  is  prescribed,  and  the  patient  should  be  seen  on 
the  second  or  third  day,  when  the  circulation  in  the  loose  parts 
and  the  antiseptic  condition  should  be  noted.  If  gangrenous 
areas  are  present,  they  should  be  removed;  if  granulation  does 
not  establish  itself,  it  should  be  stimulated  by  cleansing  the  sur- 
face with  a  curet  or  by  the  application  of  tincture  of  iodin;  and 
if  sutures  have  been  used,  they  should  be  removed  as  soon  as 
the  parts  will  retain  their  normal  position  without  their  support. 


352  TREATMENT  AFTER  EXTRACTION 


TRAUMATIC  INJURY  TO  THE  ALVEOLAR  PROCESS. 

The  alveolar  process  is  not,  as  a  rule,  iiijiired  where  the  extrac- 
tion is  a  sinii:)le  operation,  but  there  are  cases  where  it  is  impossi- 
ble to  remove  the  tooth  without  causing  some  traumatic  injury 
to  this  tissue,  and  there  are  other  cases  where  the  injury  is 
caused  by  accident. 

Loose  Spicula. 

Treatment. — Any  small  fractured  piece  or  loose  spiculum  of 
process  should  be  washed  away  with  the  syringe  or  removed  with 
tweezers.  Where  such  piece  is  adherent  to  the  gum  tissue,  it 
may  be  necessary  to  dissect  it  from  this  tissue  before  it  can  be 
removed,  which  is  done  by  holding  the  fractured  part  with  the 
tweezers  and  cutting  it  loose  with  a  lancet.  Detached  pieces  of 
process,  if  allowed  to  remain,  will  often  irritate  the  parts  for 
several  weeks  before  they  come  to  the  surface  and  are  removed, 
sometimes  prompting  a  person  who  has  had  a  tooth  extracted  to 
remark  that  at  the  time  of  the  extraction  a  part  of  the  jaw  bone 
was  broken  and  pieces  of  it  came  out  several  weeks  afterward. 

Sharp  or  Irregular  Margins. » 

Treatment. — Where  any  part  of  the  process,  as  the  result  of  an 
extraction,  has  irregular  or  sharp  edges,  they  should  be  cut  away 
with  forceps  or  with  a  bur  in  the  manner  described  under 
"Exposed  Process"  (page  355),  as  such  projection  will  often 
prove  an  irritant  to  the  gum  tissue,  and  thus  delay  the  closure 
of  the  wound.  As  these  projections  are  only  gradually  resorbed 
after  the  normal  physiologic  functions  have  been  restored  in  the 
parts,  their  removal  will  often  greatly  shorten  the  time  in  which 
normal  conditions  are  again  established.  This  procedure  is  im- 
portant where  a  number  of  teeth  have  been  removed  and  their 
loss  is  to  be  replaced  by  artificial  restoration. 

Fractured  Margin  and  Septum. 

Treatment. — A  fracture  of  the  margin  of  the  alveolar  process 
or  of  the  septum  separating  the  roots  is  not  an  infrequent  occur- 
rence in  the  extraction  of  a  multiple-rooted  tooth,  as  the  diver- 
gence of  the  roots  is  often  so  great  as  to  prevent  their  release 


TRAUMATIC  INJURY  TO  ALVEOLAR  PROCESS  353 

from  the  socket  without  such  an  accident ;  or  it  may  be  necessary 
to  carry  a  tooth  laterally  to  effect  its  release,  which  will  often 
have  the  same  result.  Where  the  detached  part  is  entirely  car- 
ried away,  no  further  attention  need  be  given  to  it  than  to  see 
that  no  shari3  points  are  left  unrounded.  If  the  fractured  part 
remains  loosely  attached  to  the  gum  tissues,  it  is  seldom  advisa- 
ble to  attempt  to  readjust  it,  but  should  be  removed  as  described 
under  "Loose  Spicula"  (page  352),  as  such  removal  will  cause 
only  a  slight  depression  at  the  point  of  fracture  and  entail  no 
permanent  injury.  Where  the  septum  separating  the  extracted 
tooth  from  an  adjoining  tooth  is  fractured,  but  not  entirely  car- 
ried away,  it  should  be  carefully  pressed  back  into  position  as  a 
protection  to  the  tooth  that  is  to  remain. 

Extensive  Fracture. 

Treatment. — Where  the  fracture  involves  an  extensive  area  of 
the  process,  but  the  part  is  not  carried  away  with  the  tooth,  it 
should  be  carefully  pressed  back  into  position,  where  it  will 
usually  be  retained  without  further  support.  Wherever  possible, 
the  carrying  away  of  a  large  area  of  process  should  be  avoided, 
and,  if  during  an  operation  it  is  observed  that  an  extensive  frac- 
ture of  the  process  has  occurred,  the  extraction  should  be  discon- 
tinued and  the  process  detached  from  the  tooth,  after  which  the 
extraction  is  completed.  If  quite  an  area  of  process  is  suddenly 
separated  entirely  from  the  bony  structure  during  an  extraction, 
of  which  accident  a  number  of  cases  are  shown  in  Fig.  187,  the 
gum  tissue  should  not  be  carried  away  with  it,  but  the  tooth 
should  be  released  and  the  gum  tissue  carefully  dissected  from 
the  fractured  process,  so  as  to  avoid  extensive  laceration  of  the 
soft  tissue  and  to  retain  as  much  of  it  as  possible  in  order  to 
protect  the  underlying  bony  structure,  which  would  otherwise 
be  exposed.  Where,  however,  so  much  of  the  osseous  tissue  has 
been  removed  that  the  part  remaining  does  not  give  adequate 
support  to  the  soft  tissue,  the  latter  should  not  be  permitted  to 
fold  over  the  process  to  such  an  extent  as  to  entirely  cover  the 
space  that  was  occupied  by  the  extracted  tooth,  but  provision 
should  be  made  for  drainage,  which  is  done  by  inserting  a  gauze 
dressing  lightly  in  the  socket  of  the  extracted  tooth.  The  dress- 
ing should  be  removed  the  following  day,  and,  where  necessary. 


354  TREATMENT  AFTER  EXTRACTION 


Fig.  187. — Fracture   of  the   alveolar  process.     Illustration  shows  various   cases   of  frac- 
ture of  the  process. 


EXPOSED  PROCESS  355 

a  new  dressing  applied  daily  until  the  tissue  will  remain  in  posi- 
tion without  further  support.  The  renewal  of  the  dressing 
should  be  discontinued  as  soon  as  possible  where  the  socket  is 
further  protected  by  stimulating  a  healthy  blood  clot. 

In  any  treatment  of  a  fractured  process  where  an  attempt  has 
been  made  to  retain  the  part  detached,  the  progress  of  repair 
should  be  noted,  and,  where  there  is  a  failure  in  the  establish- 
ment of  an  osseous  union,  the  fractured  part  should  be  removed 
to  prevent  further  irritation  and  possible  necrosis. 

Where  the  patient  becomes  aware  that  a  fracture  has  occurred, 
it  is  advisable,  to  avoid  alarm  and  possible  misapprehension  as 
to  the  gravity  of  the  condition,  to  make  an  explanation  of  the 
nature  of  the  fracture,  which  should  be  made  in  language  com- 
mensurate with  the  intelligence  of  the  j^atient.  A  dry  specimen 
of  the  mandible  from  which  a  number  of  teeth  were  removed 
prior  to  death  of  the  subject  will  serve  to  practically  illustrate 
such  a  case  and  to  more  effectually  disabuse  the  mind  of  the 
patient  of  the  idea  that  the  injury  is  of  the  jaw  proper. 

EXPOSED  PROCESS. 

Where,  after  extraction,  there  is  not  sufficient  gum  tissue  to 
fold  over  and  protect  the  alveolar  process,  the  exposed  surface, 
if  allowed  to  remain  unprotected,  may  become  very  painful  and 
will  often  necrose.  Such  a  condition  may  result  from  a  number 
of  causes — e.  g.,  where  relocated  attempts  have  been  made  to 
apply  the  forceps  to  a  root  or  tooth  that  is  deeply  seated ;  where 
the  gum  tissue  is  carried  away  with  the  extracted  tooth;  where 
approximating  teeth  are  extracted  at  the  same  sitting,  and  the 
alveolar  margins  and  interproximal  alveolar  septa  are  thick 
and  dense,  and  project  to  such  an- extent  that  the  soft  tissues  do 
not  fold  over  and  protect  them  (Fig.  188).  This  is  not  an  un- 
common condition  presented  after  extraction  in  the  case  of  ad- 
vanced age,  where  there  is  more  or  less  atrophy  of  the  soft  tissue 
around  the  necks  of  the  teeth. 

Treatment. — Where  the  process  is  exposed,  the  patient 
usually  applies  the  tongue  to  it,  and  not  infrequently  thrusts  a 
finger  into  the  wound,  with  the  remark  that  all  of  the  tooth  has 
not  been  extracted.  The  patient  should  be  cautioned  in  an 
inoffending  manner  against  such  acts,  and  be  advised  as  to  the 
nature  and  function  of  this  tissue,  the  explanation  being  made 


356  TREATMENT  AFTER  EXTRACTION 

that  its  removal  will  assist  nature's  process  of  repairing  the 
lesion. 

Where  the  gum  tissue  does  not  fold  over  the  surface  of  the 
alveolus  on  the  lingual  or  buccal  margin  of  the  socket,  enough  of 
the  exposed  area  of  process  should  be  cut  away  to  allow  the  gum 
tissue  to  cover  the  exposed  part.  The  removal  of  the  process  is 
best  accomplished  with  Standard  forceps  No.  2  (Fig.  2)  in  the 
superior  arch  and  with  Standard  forceps  No.  6  (Fig.  7)  in  the 
inferior  arch.  If  the  soft  tissue  is  firmly  adherent  to  the  alveo- 
lus, the  latter  is  cut  away  with  a  bur,  care  being  taken  not  to 
lacerate  the  gum  tissue.     Where  the  septum  that  was  between 


Fig.   188. — Exposed  process. 

the  roots  of  a  molar  tooth  or  that  separated  two  teeth  which 
have  been  extracted  is  very  prominent,  it  also  should  be  reduced 
by  cutting,  which  can  be  readily  accomplished  with  the  forceps. 
The  socket  is  flushed  with  an  antiseptic  solution  to  remove  any 
fragments  of  bone,  and  a  healthy  blood  clot  is  stimulated  to  pro- 
tect the  wound. 

DILATED  SOCKET. 

A  tooth  that  is  not  firmly  attached  to  the  alveolus,  or  has  only 
short  fused  roots,  can  be  removed  from  its  position  in  the  arch 
with  very  little,  if  any,  dilatation  of  the  socket,  but  it  is  impossi- 
ble to  extract  a  tooth  with  markedly  divergent,  crooked,   or 


DILATED  SOCKET 


357 


hypercementosed  roots  without  dilating  the  socket.  Where  lack 
of  space  for  the  passage  of  a  tooth  necessitates  its  removal  lat- 
erally, the  socket  will  be  dilated,  and  such  condition  occurs  more 
frequently  with  the  molar  teeth.  Fig.  189  illustrates  a  typical 
case  of  dilated  socket,  in  which  A  shows  an  inferior  first  molar 
tooth  with  divergent  roots,  and  B  shows  approximately  the  ex- 
tent of  dilatation  of  the  socket  caused  by  the  extraction  of  such 
tooth.  In  the  superior  arch  dilatation  usually  affects  the  buccal 
wall  of  the  socket,  while  in  the  inferior  arch  both  buccal  and 


B 

Fig.  189. — Dilatation  of  the  socket.  A,  markedly  diverg-ent  roots  of  an  inferior  first 
molar;  B,  dilatation  of  the  socket  as  the  result  of  extracting  a  tooth  with"  divergent 
roots. 


lingual  walls  may  be  displaced,  except  in  the  ease  of  the  third 
molar,  where  the  dilatation  usually  affects  only  the  lingual  wall. 
Treatment. — A  dilatation  of  the  socket  distends  both  the  hard 
and  soft  tissues,  and,  if  not  reduced,  will  cause  increased  and 
prolonged  inflammation,  with  accompanying  pain.  Where  the 
socket  is  only  slightly  dilated,  the  injury  is  usually  at  the  orifice, 
and  the  dilated  parts  are  restored  to  their  normal  position  with 
the  index  finger.  The  dilatation  thus  treated  will  cause  little 
more  disturbance  than  if  it  had  not  occurred. 


358 


TREATMENT  AFTER  EXTRACTION 


Where  the  socket  is  extensively  dilated,  and  the  lingual  and 
buccal  walls  of  the  socket  are  affected,  they  are  pressed  back  into 
their  normal  position  with  the  thumb  and  index  finger  (Fig.  190). 
Care  should  be  taken  not  to  press  the  walls  too  far,  as  this  will 
cause  as  much  injury  as  to  leave  them  dilated.  The  operator,  as 
he  passes  his  finger  over  the  sides  of  the  socket,  determines  the 
amount  of  displacement,  and  the  strength  of  the  alveolus  is  con- 
veyed to  him  by  this  touch.  Pressing  the  affected  walls  back  to 
their  normal  position  is  more  or  less  painful,  and  should  be  done 
before  the  patient  recovers  where  a  general  anesthetic  has  been 
administered.     If  the  dilitation  is  in  the  region  of  the  lingual 


Fig.  190. — Same  subject   as  Fig.   189.     iViethod   of   applying   tlie   tliumb  and   index   finger 

to  correct  a  dilated  socltet. 

plate  of  the  third  molar,  care  should  be  taken  to  make  a  complete 
replacement.  When  the  dilatation  has  been  corrected,  the  socket 
is  flushed  and  a  healthy  blood  clot  allowed  to  form  for  its  pro- 
tection. 

In  all  cases  of  traumatic  injury  to  the  alveolar  process  caused 
by  the  extraction  of  a  tooth,  the  cleansing  of  the  mouth  and  the 
washing  of  the  wound  with  antiseptics,  as  given  under  ''Extrac- 
tion Without  Complications"  (page 349),  should  be  followed  with 
increased  vigilance,  and  any  exposed  surface  that  cannot  be 
protected  by  a  blood  clot  or  by  a  gauze  dressing  should,  in  addi- 
tion to  the  use  of  mild  antiseptics,  be  touched  lightly  with  a 


ALVEOLITIS  359 

10-percent  solution  of  nitrate  of  silver  every  twenty-four  hours 
until  healthy  granulation  is  established. 

FOREIGN  BODIES  IN  THE  SOCKET. 

Where  a  number  of  teeth  are  extracted  at  the  same  sitting, 
there  is  a  greater  probability  that  salivary  calculi,  tillings,  or 
loose  fragments  of  tooth  may  enter  the  socket  of  another  tooth, 
and,  if  permitted  to  remain,  become  an  irritant  and  delay  the 
healing  of  the  wound.  This  condition  should  be  especially 
guarded  against  when  extracting  teeth  in  both  the  inferior  and 
superior  arches  at  the  same  sitting,  as  after  the  removal  of  the 
inferior  teeth  parts  of  a  fractured  tooth  from  the  superior  arch 
may  drop  into  the  mouth  and  enter  a  socket  of  one  of  the  ex- 
tracted inferior  teeth. 

Where  a  fragile  root  is  extracted,  parts  of  it  will  often  remain 
attached  to  the  gum  tissue,  and  the  fragments  are  frequently 
overlooked  on  completion  of  the  operation.  The  operator  may 
examine  only  the  extracted  root,  and,  not  perceiving  any  positive 
fracture,  will  conclude  that  the  root  is  intact  and  that  nothing 
remains  in  the  socket.  Parts  of  the  mesial  and  distal  sides  of 
the  root,  with  which  the  beaks  do  not  come  in  contact,  may  re- 
main attached  to  the  gum  tissue,  and,  when  this  occurs  and  is 
not  observed  by  the  operator,  the  patient  will  usually  call  atten- 
tion to  the  occurrence,  being  under  the  impression  that  the  tooth 
has  not  been  entirely  extracted. 

In  view  of  the  probability  of  foreign  particles  entering  the 
wound  or  parts  of  a  broken-down  tooth  remaining  in  the  socket, 
it  is  advisable  to  carefully  examine  the  socket  and  remove  any 
foreign  body  that  may  be  present  by  irrigating  with  an  anti- 
septic solution,  or  take  it  out  with  tweezers  or  a  probe.  Where 
a  part  of  the  tooth  remains,  but  is  not  firmly  attached  to  the  gum 
tissue,  it  is  readily  removed  with  the  Derenberg  tweezers.  Where 
the  remaining  part  is  of  considerable  size  and  the  union  is  firm, 
the  part  is  held  with  Derenberg  tweezers  and  separated  from  the 
soft  tissue  with  the  lancet. 

ALVEOLITIS. 

Alveolitis  is  an  inflammation  of  the  peridental  membrane  or  of 
the  membranous  lining  of  the  alveolus,  and  the  term  as  here  used 
applies  to  the  various  grades  of  pericemental  disturbances  where 


360  TREATMENT  AFTER  EXTRACTION 

pus  is  not  present.  The  term  also  includes  pericementitis  pro- 
duced by  nonseptic  causes,  among  which  are  the  following :  trau- 
matic pericementitis  caused  by  external  violence  to  a  tooth  by  a 
blow,  fall,  or  attempted  extraction,  the  latter  cause  often  having 
associated  with  it  more  or  less  injury  of  the  alveolar  margins; 
traumatic  pericementitis  caused  by  internal  violence,  such  as 
the  projection  of  a  pivot  wire,  broach,  or  drill  through  the  apical 
foramen;  hypercementosis,  with  which  there  is  occasionally  asso- 
ciated mild  inflammation,  which  is  often  greatly  increased  by  the 
traumatic  injury  that  cannot  be  avoided  in  tlie  extraction;  acute 
septic  pericementitis  in  the  initial  stages  and  before  the  forma- 
tion of  pus. 

In  most  cases  of  alveolitis  where  extraction  is  indicated  the 
tooth  is  very  sensitive  to  the  slightest  touch,  and  the  application 
of  an  instrument  causes  excruciating  pain.  The  tooth  may  be 
loosened  and  slightly  extruded,  which  may  assist  the  extraction, 
but  should  not  be  relied  on,  as  it  may  be  quite  as  difficult  to  sepa- 
rate the  tooth  from  its  attachment  as  would  be  the  case  if  alveo- 
litis were  not  present.  In  such  case  the  operation  should  be  per- 
formed, if  at  all  practicable,  under  a  general  anesthetic. 

Treatment. — The  extraction  of  the  tooth,  which  will  relieve 
the  pressure  on  the  inflamed  membrane,  may  cause  the  pain  to 
subside,  and  usually  has  that  effect  if  the  extraction  is  followed 
by  a  rather  profuse  hemorrhage.  When  the  bleeding  is  not  free, 
it  should  be  encouraged  by  a  liberal  use  of  warm  water.  If  the 
pain  continues  after  the  extraction,  the  wound  is  irrigated  with  a 
mild  antiseptic  solution,  and  whatever  fluids  remain  in  it  are 
taken  up  with  absorbent  cotton.  Another  piece  of  absorbent 
cotton,  shaped  to  approximate  the  form  of  the  root  that  has  been 
removed,  is  then  dipped  into  campho-phenique,  quickly  carried 
to  the  apex  of  the  socket,  and  allowed  to  remain  for  several  min- 
utes. To  make  the  treatment  more  effective,  the  parts  should 
be  kept  free  from  moisture  during  the  medication.  After  the 
removal  of  the  dressing,  the  wound  is  sealed,  when  necessary, 
with  a  blood  clot  by  touching  the  gum  tissues  with  a  sterilized 
instrument.  A  mouth  wash,  as  given  under  ''Extraction  With- 
out Complications"  (page  349),  is  prescribed,  and  the  patient  is 
instructed  to  return  for  further  treatment  on  the  recurrence  of 
pain  or  in  case  the  inflammatory  conditions  do  not  subside. 

Where  the  patient  is   affected   with  neurasthenia   or   other 


ACUTE  SEPTIC  PERICEMENTITIS  361 

nervous  disorder,  potassium  iodid  in  lO-grain  doses,  taken  three 
times  daily  after  meals,  is  a  valuable  adjunct  to  the  local  treat- 
ment, in  addition  to  which  the  patient  should  avoid  all  forms 
of  excitement  and  maintain  as  perfect  rest  as  possible. 

POST-OPERATIVE  ALVEOLITIS. 

This  is  a  nonseptic  inflammation  of  the  tooth  socket  occurring 
some  hours  after  the  operation,  and  usually  occurs  in  cases  of 
difficult  extraction,  such  as  the  removal  of  hypercementosed  teeth, 
of  superior  or  inferior  molar  teeth  with  divergent  roots  (which 
cause  considerable  dilatation  of  the  socket),  of  inferior  molar 
teeth  with  the  roots  curved  around  the  septum  separating  them 
(the  septum  having  been  carried  away  with  the  tooth  during  the 
extraction),  or  any  considerable  traumatic  injury  to  the  alveolar 
process.  Sometimes  the  cause  is  obscure,  but  may  be  due  to  the 
density  of  the  blood  clot  or  some  systemic  disease  or  idiosyn- 
crasy. 

Treatment. — The  blood  clot  is  removed  by  irrigation  with 
warm  water  or  carefully  picked  out  with  tweezers,  after  which 
the  treatment  is  the  same  as  in  "Alveolitis"  (page  359),  except 
that  in  aggravated  cases  95-percent  phenol  may  be  substituted 
for  campho-phenique. 

ACUTE  SEPTIC  PERICEMENTITIS. 

The  term  acute  septic  pericementitis  includes  all  foiTus  of 
acute  inflammatory  conditions  about  the  root  of  a  tooth,  due  to 
the  invasion  of  septic  or  pyogenic  organisms,  where  the  disease 
has  advanced  to  the  stage  of  pus  formation.  This  condition  is 
variously  described  as  dento-alveolar  abscess,  acute  alveolo- 
dental  abscess,  acute  suppurative  alveolitis,  acute  alveolar 
abscess,  etc.  The  term  embraces  also  osteitis — which  develops 
very  early  in  the  pus  formative  period  at  tlie  apex  of  a  root — 
abscesses  that  occasionally  develop  at  the  gum  margins  or  at 
some  intermediate  part  of  the  pericementum,  and  abscesses  that 
develop  around  impacted  teeth  or  originate  beneath  the  gum 
overlying  an  inferior  third  molar. 

The  advisability  of  extraction  in  acute  septic  pericementitis  is 
frequently  a  moot  question,  but  operation  is  favored  wherever 
the  general  health  of  the  patient  will  permit.    The  claim  has  been 


362  TREATMENT  AFTER  EXTRACTION 

made  that  the  continuation  of  pus  formations  after  extraction 
and  the  possible  infection  of  other  tissues  as  a  result  render  the 
condition  worse  than  before  the  extraction,  but,  if  such  infection 
occurs,  it  will  be  due  to  the  retention  of  pyogenic  organisms 
beneath  the  blood  clot  or  to  a  secondary  infection  from  ex- 
ternal organisms,  both  of  which  causes  should  be  averted  by  the 
proper  procedure  before  and  after  operating.  The  retention 
of  the  tooth  will  simply  hold  the  pyogenic  bacteria,  and  any 
metastatic  infection  that  occurs  after  the  extraction  would  un- 
doubtedly take  place  if  the  tooth  were  retained.  The  removal 
of  the  tooth  in  such  case  opens  the  way  to  the  seat  of  infection, 
establishes  a  means  of  exit  for  the  pus,  and  allows  cleansing  and 
sterilization  of  the  affected  area,  which  latter  should  be  judi- 
ciously done  in  the  post-extraction  treatment,  at  the  same  time 
protecting  the  wound  from  the  invasion  of  any  external  micro- 
organisms. 

Treatment. — In  acute  septic  pericementitis  the  pericementum 
is  highly  inflamed,  the  tissue  much  swollen,  and  the  tooth  ex- 
tremely sensitive  to  the  slightest  touch.  Local  anesthetics  are 
of  little  value  when  such  conditions  are  present,  and,  wherever 
possible,  the  operation  should  be  performed  under  a  general 
anesthetic.  In  a  majority  of  cases  the  patient  has  suffered  pain, 
had  loss  of  sleep,  and,  in  addition,  has  worried  with  the  thought 
of  the  ''pain  of  the  extraction"  until  there  is  a  great  loss  of 
nervous  force,  the  system  being  then  in  no  condition  to  endure 
further  pain. 

Preliminary  to  the  extraction,  all  parts  of  the  mouth  are  thor- 
oughly cleansed  with  an  antiseptic,  and  the  gum  tissue  and  area 
about  the  tooth  to  be  removed  are  irrigated  with  the  same 
solution,  in  order  that  the  oral  cavity  may  be  rendered  as  free  as 
possible  of  pathogenic  bacteria,  as  such  organisms  as  bacillus 
pneumoniae  and  bacillus  diphtherioe  are  not  infrequently  found 
in  the  mouths  of  even  healthy  individuals.  Following  the  re- 
moval of  the  tooth,  the  pus  is  evacuated,  and  this  should  be  done 
before  the  recovery  from  the  anesthetic.  The  abscess  is  usually 
freely  opened  by  the  removal  of  the  offending  tooth,  and  in  such 
case  the  pus  is  driven  out  by  applying  pressure  on  each  side  of 
the  socket  with  the  thumb  and  index  finger.  If  the  extraction 
does  not  afford  a  free  vent  for  the  pus,  and  it  is  retained  in  a 
recess  burrowed  in  the  process,  a  pointed  but  slightly  curved 


ACUTE  SEPTIC  PERICEMENTITIS  363 

lancet  is  directed  to  the  apex  of  the  socket  and  sufficient  pressure 
applied  to  penetrate  the  alveolus,  which  will  provide  the  neces- 
sary opening  for  drainage.  Where  the  pus  has  burrowed  through 
either  plate  of  the  process,  but  is  retained  beneath  the  perios- 
teum or  gum  tissue,  it  is  usually  preferable  to  lance  the  gum  at 
the  point  indicated  by  the  pointing  of  the  abscess  than  to  try 
to  force  the  pus  through  the  opening  created  by  the  extraction 
of  the  tooth.  The  pus,  as  it  leaves  the  socket,  is  not  allowed  to 
pass  into  the  mouth,  but  is  caught  with  absorbent  cotton  or 
gauze  until  the  patient  has  recovered  from  the  anesthetic.  After 
the  mouth  has  been  rinsed  with  warm  water  to  promote  hemor- 
rhage and  to  free  it  of  blood  and  saliva,  the  socket  is  syringed 
with  sterilized  warm  water,  which  is  followed  with  an  antiseptic 
wash  used  in  the  same  manner.  Potassium  permanganate, 
5  grains  to  1  ounce  of  water,  is  an  excellent  antiseptic  for  this 
purpose,  but  has  a  disagreeable  taste.  Where  this  wash  is 
objectionable,  one  of  the  mouth  washes  mentioned  under  ''Ex- 
traction Without  Complications"  (page  349)  may  be  used.  After 
the  application  of  the  mouth  wash,  95-percent  phenol  or  full- 
strength  lysol  is  introduced  into  the  socket  in  the  same  manner 
as  campho-phenique  is  applied  in  alveolitis  (page  359),  and 
allowed  to  remain  from  three  to  five  minutes,  when  it  is  removed 
and  a  gauze  dressing  is  applied.  The  gauze  should  be  packed 
only  firm  enough  in  the  socket  to  exclude  foreign  matter,  as 
drainage  must  be  maintained.  A  suitable  mouth  wash  (page  350) 
is  prescribed,  which  should  be  used  often  and  freely.  The  gauze 
dressing  should  not  remain  longer  than  twenty-four  hours,  when 
it  is  removed  and  the  previous  treatment  repeated.  Where  the 
inflammatory  condition  rapidly  subsides,  the  application  of 
95-percent  phenol  may  be  omitted  in  the  second  treatment,  and 
its  use  is  seldom  indicated  in  any  case  after  the  third  treatment. 
The  wound  is  dressed  daily  until  healthy  granulation  is  estab- 
lished, when  it  is  protected  with  a  healthy  blood  clot,  and  further 
treatment  is  discontinued,  save  the  use  of  a  mouth  wash. 

It  will  be  understood  that  there  can  be  no  specific  method  for 
treating  all  forms  of  acute  septic  pericementitis,  but  the  above 
treatment,  modified  to  suit  individual  conditions,  has  proven  very 
satisfactory,  and  will  serve  as  a  basis  of  operative  procedure  in 
this  very  prevalent  ailment. 

Any  gangrenous  tissue  that  may  appear  should  be  removed, 


364  TREATMENT  AFTER  EXTRACTION 

and,  where  the  acute  inflammatory  conditions  are  not  mitigated 
by  the  time  of  the  second  treatment,  the  wound  should  be  care- 
fully examined  to  determine  whether  proper  drainage  has  been 
maintained.  Where  the  inflammation  is  diffused,  as  in  lym- 
phangitis, or  where  there  is  any  febrile  disturbance,  constitu- 
tional treatment,  as  a  precaution  against  possible  toxemia  or 
septicemia,  should  be  administered  and  directed  toward  the 
elimination  of  any  ptomaines  that  may  have  entered  the  circula- 
tion. For  this  purpose  a  saline  purgative  should  be  prescribed, 
and,  where  indicated,  diuretics  may  also  be  taken.  Aspirin  in 
5-grain  doses,  taken  every  three  hours,  or  oftener  if  required, 
may  be  given  where  there  is  local  pain,  restlessness,  or  any 
marked  nervous  disturbances. 

Where  the  acute  inflanmiatory  conditions  subside,  but  healthy 
granulation  is  not  established  within  a  reasonable  time,  the 
wound  should  be  treated  as  given  under  "Chronic  Septic  Peri- 
cementitis" (page  365). 

POST-OPERATIVE  INFECTION. 

Precautionary  measures  should  always  be  taken  to  prevent  in- 
fection of  the  affected  parts  after  an  operation,  but,  if  such  infec- 
tion occurs  and  the  patient  comes  under  the  care  of  another  than 
the  one  who  performed  the  operation,  the  case  should,  where 
possible,  be  referred  to  the  former  operator  or  he  should  be  con- 
sulted, as  it  is  presumed  that  he  will  be  familiar  with  the  original 
conditions  and  the  treatment  applied  at  the  time.  There  should 
not  be  a  disposition  to  attribute  the  cause  of  the  disturbance 
to  the  use  of  unclean  instruments,  for,  while  instruments  that 
have  not  been  properly  sterilized  are  sometimes  used,  it  must  be 
borne. in  mind  that  the  site  of  an  extraction  is  prone  to  infection 
and  that  the  larger  number  of  dental  lesions  are  in  a  state  of 
infection  from  the  time  of  their  origin,  not  to  mention  the  prob- 
able neglect,  on  the  part  of  the  patient,  of  the  treatment  after 
extraction.  To  consider  a  wound  created  by  the  removal  of  a 
tooth  as  trivial  is  the  general  rule  with  patients,  and  this  feeling 
of  indifference  usually  leads  to  an  utter  disregard  of  instructions 
given  for  its  subsequent  care  and  treatment. 

Treatment. — The  treatment  in  post-operative  infection  is  the 
same  as  for  a  similar  condition  at  the  time  of  operating. 


CHRONIC  SEPTIC  PERICEMENTITIS  365 

TOXEMIA  AND  SEPTICEMIA. 

Toxemia  is  caused  by  the  products  (toxins)  of  an  abscess  or  of 
an  infectious  inflammation  entering  the  circulation,  and,  where 
the  organisms  themselves  enter,  a  general  septic  intoxication, 
or  septicemia,  may  result.  The  effects  of  either  form  of  poison- 
ing on  the  general  system  do  not  differ  greatly,  except  that  the 
development  of  the  disease  in  septicemia  takes  longer  time,  but, 
when  developed,  the  condition  is  more  aggravated  and  the  prog- 
nosis is  more  uncertain. 

The  symptoms  vary  according  to  the  nature  of  the  toxins,  or 
the  kind  and  quantity  of  bacteria  entering  the  system.  The  local 
symptoms  of  suppuration,  redness,  heat,  pain,  and  swelling  are 
usually  aggravated.  The  general  symptoms  are  fever,  which  is 
usually  preceded  by  a  chill,  loss  of  appetite,  headache,  and  de- 
pression, which  may  be  followed  by  nausea,  vomiting,  muscular 
weakness,  quick  respiration,  feeble  pulse,  and  general  prostra- 
tion. 

Treatment. — Medical  cooperation  should  be  obtained  in  order 
that  every  possible  means  may  be  afforded  to  effect  a  cure.  The 
treatment  for  conditions  that  occur  after  the  operation  is  the 
same  as  for  a  similar  state  that  may  be  present  at  the  time  of 
the  operation.  The  local  treatment  is  to  stop  the  source  of  the 
intoxication,  if  possible,  by  removing  all  foreign  matter  and  gan- 
grenous tissue,  and  thoroughly  cleansing  and  sterilizing  the 
parts.  (For  local  treatment  see  ''Acute  Septic  Pericementitis," 
page  361.)  The  general  treatment  consists  in  the  administration 
of  tonics,  using  stimulants  in  case  of  depression,  and  keeping  the 
excretory  organs  active  by  the  administration  of  diaphoretics, 
diuretics,  and  saline  cathartics,  as  may  be  indicated. 

CHRONIC  SEPTIC  PERICEMENTITIS. 

This  is  a  state  in  which  pus  is  continuously  formed  at  the  sac- 
rifice of  the  apical  pericementum  and  contiguous  parts.  This 
condition  is  sometimes  termed  chronic  apical  abscess,  and,  if  of 
long  standing,  there  is  usually  considerable  destruction  of  the 
tissue  about  the  root  or  tooth  affected  (Fig.  191).  The  pocket 
that  has  formed  may  fill  with  pus,  which  is  discharged  through  a 
root  canal  or  through  a  fistula,  and  the  treatment  following  the 


166 


TREATMENT  AFTER  EXTRACTION 


removal  of  the  tooth  is  the  same  in  either  case,  unless  the  fistula 
opens  externally  to  the  oral  cavity  or  at  some  point  remote  from 
the  abscess  pocket.  When  the  pocket  is  not  filled  with  pus,  it 
will  contain  a  growth  resembling  a  cyst,  which  is  largely  com- 
posed of  accumulations  of  serum  or  degenerated  pus.  This 
formation  is  attached  to  the  root,  and,  if  small,  it  is  usually  car- 
ried away  with  the  root  at  the  time  of  extraction,  but,  when 
large,  it  is  ruptured  from  the  root  and  remains  in  the  socket. 

Treatment. — On  removal  of  the  tooth  the  area  affected  by  the 
abscessed  condition  is  curetted,  using  for  this  purpose,  where 
necessary,  a  bur  instead  of  a  curet,  and  all  broken-down  or  ne- 
crosed tissue  is  removed.  Where  the  cystoid  remains,  a  small 
curet  (Fig.  37)  is  passed  into  the  pocket  containing  the  cystoid, 
when  it  is  broken  up  and  removed  with  the  same  instrument,  or 


Fig.    191. 


-Radiographs    of    teetli    sliowing   tlie    effect    of    chronic    septic    pericementitis 
about  the  roots. 


the  parts  are  flushed  with  a  syringe.  When  operating  under  a 
general  anesthetic,  the  curetting  should  be  attended  to  before 
the  recovery  of  the  patient  from  the  anesthetic,  but,  where  no 
anesthetic  has  been  administered,  it  may,  by  the  exercise  of  a 
little  care,  be  done  without  causing  any  considerable  pain,  as  the 
parts  are  not  acutely  sensitive  in  this  form  of  pericementitis. 

After  thoroughly  irrigating  the  socket  with  an  antiseptic 
solution  to  remove  any  broken-down  tissue,  silver  nitrate  in 
10-percent  solution  is  carefully  applied  to  the  parts  of  the  socket 
that  are  affected  by  the  inflammatory  condition.  To  obtain  the 
maximum  efficiency  of  the  medicament,  the  parts  should  be 
cleared  of  all  moisture  previous  to  the  application,  and  kept  in 
that  condition  until  the  socket  has  been  packed  with  a  gauze 
dressing.  The  dressing  should  be  packed  rather  tightly  into  the 
socket  in  order  to  better  protect  it  from  the  invasion  of  exter- 


iiEPTIC  PERICEMENTITIS   WITH  EXTERNAL   FISTULA  367 

nal  microorganisms.  If  preferred,  10-percent  zinc  chlorid  or 
25-percent  phenosulplionic  acid  may  be  used  instead  of  the 
nitrate  of  silver.  The  gauze  dressing  is  removed  the  following 
day,  when  the  parts  are  carefully  cleansed  and  the  entire  area 
occupied  by  the  tooth,  including  all  pockets  and  fistulas,  are 
filled  with  bismuth  paste,  which  is  applied  with  a  syringe  made 
especially  for  the  purpose  (Fig.  36).  (Bismuth  paste,  intro- 
duced by  Dr.  Emil  Beck  in  1907,  consists  of  bismuth  subnitrate, 
30  parts;  vaselin,  60  parts;  paraffin,  5  parts;  wax,  5  parts.)  This 
dressing  is  allowed  to  remain  from  two  to  three  days,  and  has 
the  advantage  of  being  better  retained  than  gauze,  more  effec- 
tually protecting  the  parts,  and  stimulating  a  healthy  granula- 
tion. The  bismuth  paste  dressing  may  be  rei3eated  as  often  as 
indicated,  but  usually  two  or  three  applications  will  suffice.  A 
mouth  wash  should  be  used  several  times  daily  until  the  wound 
is  entirely  healed. 

SEPTIC  PERICEMENTITIS  WITH  EXTERNAL  FISTULA. 

Occasionally  the  fistula  leading  from  an  abscessed  area  about 
the  root  of  the  tooth  will  discharge  at  some  point  remote  from 
the  affected  tooth,  or  at  a  point  external  to  the  oral  cavity.  In 
such  case,  on  removal  of  the  tooth,  communication  is  established 
between  the  two  openings,  where  possible,  by  passing  a  soft 
blunt-pointed  probe  through  the  tract.  The  tract  is  then  thor- 
oughly irrigated  throughout  its  entire  course  with  sterilized 
warm  water,  which  is  followed  by  an  antiseptic  solution,  such  as 
potassium  permanganate  in  proportion  of  5  to  10  grains  to 
1  ounce  of  water.  After  this  has  been  done,  95-percent  phenol 
or  10-  to  25-percent  phenosulphonic  acid  is  introduced  into  the 
tract  through  the  tooth  socket,  and  carried  its  entire  length,  or 
at  least  as  far  as  the  fistula  passes  through  or  along  bony  struc- 
tures, which  is  best  done  by  wrapping  a  soft  medicator  with 
plain  gauze  and  carefully  pumping  the  medicament  into  the 
tract.  The  socket  is  securely  packed  with  antiseptic  gauze, 
which  should  be  introduced  immediately  after  the  cauterizing 
agent  and  before  the  fluids  of  the  mouth  have  entered  the  wound. 
At  the  second  treatment,  which  should  be  given  not  later  than 
thirty-six  hours  after  the  first,  the  previous  treatment  is  re 
peated,  or  instead,  after  irrigation,  the  entire  tract  may  be  filled 


368  TREATMENT  AFTER  EXTRACTION 

with  bismuth  paste.  The  paste,  if  used,  should  be  renewed 
every  two  to  four  days  until  the  entire  tract  is  healed.  A  tent 
of  gauze  may  be  retained  in  the  external  orifice  of  the  fistula  to 
])revent  a  premature  sealing  of  this  end  of  the  tract,  which 
should  be  the  last  part  to  close. 

MULTIPLE  EXTRACTIONS. 

Where  one  of  a  number  of  teeth  to  be  extracted  is  affected 
with  acute  septic  pericementitis,  the  affected  tooth  should  l)e 
removed  first  and  the  wound  treated  until  a  healthy  condition  of 
the  affected  area  has  been  obtained,  after  which  the  remaining 
teeth  are  removed,  as  the  pus  from  the  abscess  of  the  affected 
tooth  may  infect  the  wounds  of  the  teeth  not  affected  if  all  the 
teeth  are  extracted  at  the  same  sitting.  If,  when  clearing  the 
mouth  of  a  number  of  teeth,  some  of  them  are  affected  by 
chronic  septic  pericementitis,  while  the  tissue  around  the  others 
is  comparatively  healthy,  the  diseased  ones  should  be  removed 
at  the  first  sitting,  and  after  the  wounds  from  the  diseased  teeth 
have  healed  the  remaining  teeth  are  extracted.  This  method 
of  operating  in  such  case  should  be  adopted  as  a  precautionary 
measure,  as  it  may  prevent  a  possible  contamination  of  healthy 
tissue  with  the  pus  from  infected  areas. 

NECROSIS. 

Where  there  is  extensive  necrosis  about  the  root  of  an 
extracted  tooth,  whether  of  pathologic  or  chemical  origin,  all 
necrotic  tissue  should  be  removed  with  a  curet  or  cut  away  with 
a  bur.  Where  it  is  impossible  to  prevent  the  formation  of  a 
sequestrum,  it  should  be  removed  as  soon  as  exfoliation  is  com- 
plete. The  subsequent  treatment  is  to  thoroughly  sterilize  the 
parts,  stimulate  healthy  cell  formation,  and  protect  the  lesion 
with  suitable  dressings.  Tincture  of  iodin  is  very  effective  as  a 
sterilizing  agent,  as  it  penetrates  the  osseous  tissue  for  some  dis- 
tance, and  thus  sterilizes  areas  that  could  not  be  otherwise 
reached.  The  treatment  applicable  in  cases  of  chronic  septic 
pericementitis  (page  365)  applies  also  to  necrosis  about  a  tooth. 

MAXILLARY  SINUS. 

For  the  treatment  of  pathologic  conditions  of  the  maxillary 
sinus,  reference  should  be  made  to  standard  works  on  oral  sur- 


POST-EXTRACTION  PAIN  369 

gery.  Where  the  extraction  of  a  tooth  causes  an  opening  into  a 
healthy  antrum,  which  sometimes  occurs,  the  treatment  is  to  pre- 
vent the  fluids  of  the  mouth  from  passing  into  the  sinus  and  to 
keep  the  wound  aseptic.  In  washing  the  parts,  the  antiseptic 
solution  should  not  be  forced  into  the  antrum,  and,  where  the 
opening  is  too  large  to  be  sealed  with  the  blood  clot,  it  should  be 
closed  with  one  or  more  sutures. 

POST-EXTRACTION  PAIN. 

Patients  are,  as  a  rule,  under  the  impression  that  all  pain 
should  cease  with  the  extraction  of  a  tooth,  but  often  the  pain 
that  follows  an  extraction  is  quite  as  severe  as  that  which  pre- 
vailed before  the  removal  of  the  tooth.  If  post-extraction  pain 
does  not  subside  within  a  short  time  after  the  parts  have  been 
treated,  and  the  operator  has  failed  to  explain  the  probable  dura- 
tion of  such  pain,  the  patient  may  conclude  that  the  operation 
was  not  properly  performed. 

The  treatment  in  any  case  will  depend  on  the  cause  of  the  dis- 
turbance, and  a  majority  of  these  disturbances  are  directly  trace- 
able to  the  pathologic  conditions  affecting  the  tooth  at  the  time 
of  its  removal,  or  some  traumatic  injury  to  the  parts  may  have 
occurred  during  the  extraction.  The  treatment  for  these  condi- 
tions has  been  given,  and  other  conditions  not  heretofore  men- 
tioned that  may  sometimes  cause  severe  after-pain  are  as  follows : 

(1)  A  very  dense  blood  clot  may  cause  severe  pain  in  the  parts 
some  days  after  the  operation.  The  pain  is  relieved  by  remov- 
ing the  clot,  cleansing  the  socket,  and  stimulating  a  new  clot. 

(2)  A  fractured  root  left  in  sitii^  with  a  portion  of  the  pulp 
tissue  projecting  above  the  root,  will  cause  intense  pain.  Where 
it  is  not  practicable  to  remove  the  root,  the  pain  is  relieved  by  the 
application  of  95-percent  phenol,  or  by  the  removal  of  the  pulp 
tissue  under  a  general  or  local  anesthetic. 

(3)  The  hemorrhage  that  should  follow  an  extraction  is,  in 
some  instances,  almost  entirely  lacking.  In  such  case  there  is 
very  little  membranous  tissue  separating  the  tooth  from  the 
alveolus,  and,  while  there  is  no  direct  union  of  these  two  struc- 
tures, the  bony  wall  around  the  root  under  such  circumstances  is 
dense,  very  closely  approximating  the  root  which  it  supports. 
After  the  removal  of  the  tooth,  the  socket  remains  free  of  blood, 
causing  what  is  commonly  termed  ' '  dry  socket, ' '  a  condition  that 


370  TREATMENT  AFTER  EXTRACTION 

is  often  accompanied  by  severe  post-extraction  pain.  Promoting 
a  flow  of  blood  by  curettage,  or  even  by  the  use  of  a  bur  on  the 
walls  of  the  socket,  will  usually  relieve  the  pain  and  afford  a  clot 
to  protect  the  wound. 

(4)  Among  other  causes  of  dental  pain  may  be  mentioned 
chronic  malarial  poisoning,  lagrippe,  syphilis,  pain  during  preg- 
nancy, diseases  of  the  nervous  system,  etc.,  and,  while  in  these 
cases  temporary  relief  may  be  obtained  by  an  analgesic,  the 
patient  afflicted  with  any  of  these  ailments  should  be  referred  to 
the  family  physician  for  general  treatment. 

TUBERCULOSIS  AND  SYPHILIS. 

Where  tuberculosis  or  syphilis  has  caused  oral  lesions,  a  tooth 
should  be  extracted  only  after  consultation  with  the  attending 
physician,  and  the  treatment  of  the  wound  following  the  removal 
of  the  tooth  should  be  left  in  his  care,  or  the  local  treatment 
may  be  conducted  in  conjunction  with  the  physician's  systemic 
treatment. 

ORAL  LESIONS  OTHER  THAN  DENTAL. 

The  oral  cavity  is  subject  to  numerous  pathologic  conditions 
that  are  not  of  dental  origin.  The  most  common  of  these  ail- 
ments are  some  of  the  various  forms  of  stomatitis.  Gingivitis 
may  be  the  accompaniment  of  such  general  disorders  as  malaria 
and  rheumatism.  The  administration  of  lead,  mercury,  or  iodin 
may  produce  dental  disturbances.  One  of  several  forms  of 
tumors,  among  which  are  cyst  and  carcinoma,  is  sometimes  pres- 
ent. In  addition  to  these  conditions,  some  of  the  numerous 
lesions  which  so  often  occur  in  the  oral  cavity  may  indicate 
other  bodily  ailments.  Where  there  is  any  lesion  of  the  oral 
cavity  whose  pathologic  condition  may  be  aggravated  by  the 
removal  of  a  tooth,  or  where  the  wound  created  by  such  removal 
may  become  contaminated  b}^  toxins  from  such  pathologic  con- 
dition, the  operation  should  be  performed  only  after  consulting 
the  patient's  physician.  The  same  course  should  be  followed 
where  the  patient  is  afflicted  with  systemic  diseases  whose  pres- 
ence may  greatly  aggravate  the  after-effects  of  the  extraction. 
By  conducting  the  treatment  of  these  cases  in  conjunction  with 
the  attending  physician,  the  patient  will  receive  the  most  advan- 
tageous service  and  be  benefited  accordingly. 


CHAPTER  XVI. 
HEMORRHAGE. 

By  the  term  hemorrhage,  as  here  used,  is  meant  any  loss  of 
blood  from  a  tooth  socket  or  the  surroimdiug  tissue  following  an 
extraction.  The  character  of  such  hemorrhage  differs  according 
to  the  vessel  from  which  the  blood  escapes,  being  designated  as 
arterial,  venous,  and  capillary.  The  immediate  hemorrhage, 
however,  following  an  extraction  is  seldom  confined  to  any  one 
kind,  and  is  more  often  a  combination  of  the  three  kinds,  but, 
if  the  bleeding  continues,  it  may  assume  a  more  definite  char- 
acter. A  flow  of  bright  scarlet  blood  from  the  socket,  which 
flow  is  usually  rather  profuse — but  seldom  in  jets,  owing  to  the 
small  size  of  the  vessel  from  which  the  blood  is  escaping  and  the 
dejDth  of  the  vessel  in  the  tissue — is  indicative  of  arterial  hemor- 
rhage, while  a  less  profuse  supply  of  blood  of  a  dark  nature  is  a 
venous  characteristic,  and  a  capillary  hemorrhage  is  marked  by 
an  oozing  of  the  blood  from  the  raw  edges  of  the  tooth  socket, 
or  from  any  part  of  the  gaim  or  alveolar  tissue  that  may  be 
injured. 

The  sources  of  hemorrhage  following  an  extraction  without 
any  complications  are  the  gum  tissue,  periosteum,  peridental 
membrane,  and  arterial  supply  to  the  pulp  of  the  tooth,  all  of 
which  are  more  or  less  injured  by  the  operation.  In  case  of  acci- 
dent, abnormalities,  or  pathologic  conditions  the  bleeding  may 
come  from  sources  that  were,  preceding  the  operation,  appar- 
ently remote  from  the  tooth. 

Severe  hemorrhage  seldom  follows  the  removal  of  a  tooth,  and 
when  such  hemorrhage  does  occur  it  is  usually  controlled  by 
thrombosis.  There  are  conditions,  as  in  alveolar  abscess,  where 
the  formation  of  a  thrombus  should  be  delayed  by  the  adminis- 
tration of  sterilized  warm  water,  so  that  the  congestion  of  the 
tissue  may  be  more  thoroughly  relieved  before  the  hemorrhage 
ceases.  There  are  also  other  conditions  where  there  is  no  hem- 
orrhage, as  in  the  case  of  "dry  socket,"  in  which  condition  the 
flow  of  blood  is  subsequently  induced,  if  possible,  by  further  sur- 

371 


372  HEMORRHAGE 

gical  interference.  In  some  instances,  however,  a  post-extrac- 
tion hemorrhage  may  be  severe,  and  cases  of  a  fatal  termination 
have  been  reported.  After  an  extraction  the  patient  should  not 
be  dismissed  until  the  flow  of  blood  has  stopped,  or  subsided 
sufficiently  for  the  operator  to  feel  satisfied  that  the  hemorrhage 
will  be  controlled  by  natural  conditions.  This  procedure  will 
cause  little  delay,  as  only  a  few  minutes  are  required  for  the 
formation  of  the  clot  in  ordinary  cases  of  extraction. 

Hemorrhage  following  extractions  that  may  require  some  arti- 
ficial means  for  their  control  are  classified  according  to  the  time 
of  their  occurrence,  and  are  designated  as  primary,  intermediary, 
and  secondary. 

PRIMARY  HEMORRHAGE. 

The  immediate  flow  of  blood  from  a  wound  is  known  as  a  pri- 
mary hemorrhage.  Where  this  flow  continues  for  more  than  a 
few  minutes  following  an  extraction,  it  should  be  controlled  by 
artificial  means,  unless  the  tissues  are  congested  or  the  parts 
infiltrated  and  it  is  desirable  to  relieve  the  condition  before  the 
arrest  of  the  hemorrhage. 

Treatment. — Where  possible,  the  hemorrhage  should  be  con- 
trolled by  some  means  that  will  promote  the  formation  of  a  blood 
clot,  as  no  artificial  dressing  can  be  applied  that  will  so  effec- 
tually seal  the  socket  and  protect  the  parts  as  a  healthy  clot.  In 
ordinary  routine,  digital  pressure  is  applied  to  each  side  and 
over  the  socket,  which  will  usually  check  the  flow  and  is  fre- 
quently all  that  is  necessary.  If,  however,  this  procedure  does 
not  suffice,  it  may  be  followed  by  holding  hot  water  over  the 
wound,  the  water  having  been  previously  sterilized  by  boiling 
or  by  the  addition  of  enough  phenol  to  render  it  aseptic.  In  this 
connection  it  may  be  stated  that  water  as  hot  as  can  be  tolerated 
in  the  mouth  should  be  used,  as  warm  water  promotes  the  blood 
flow,  while  hot  water  acts  as  a  hemostatic. 

Certain  chemical  agents,  known  as  styptics,  may  be  used  to 
check  the  flow  of  blood,  and  are  applied  locally.  Among  the 
first  of  these,  alum  may  be  mentioned,  as  it  is  harmless  and  is 
not  unpleasant  to  the  taste.  Tannic  acid  is  efficacious  and  harm- 
less, and  may  be  readily  applied  either  in  solution  or  as  a  powder, 
but  possesses  a  disagreeable  taste.  Turpentine  is  a  powerful 
styptic,  but  is  seldom  used  on  account  of  its  objectionable  odor 


INTERMEDIARY  HEMORRHAGE  373 

and  taste.  The  use  of  such  agents  as  nitrate  of  silver  and  per- 
chlorid  of  iron  is  not  advised,  as  they  are  caustic,  and,  unless  used 
with  great  care  and  in  very  small  quantities,  will  cause  a  slough- 
ing of  the  surfaces  to  which  they  are  applied,  possibly  resulting 
in  a  secondary  hemorrhage.  Before  the  application  of  a  styptic, 
the  socket  and  affected  parts  should  be  thoroughly  cleansed  with 
a  mild  antiseptic  solution  applied  with  a  syringe. 

If  the  above  methods  of  treatment  fail  to  arrest  the  hemor- 
rhage, resort  should  be  had  to  pressure,  which  is  effected  by 
packing  the  socket  in  the  manner  that  is  most  applicable  to  the 
particular  case.     (For  various  methods  of  packing  see  below.) 

INTERMEDIARY  HEMORRHAGE. 

Bleeding  that  recurs  within  twenty-four  hours  of  the  operation 
is  termed  intermediary  hemorrhage.  Such  hemorrhage  may  be 
induced  by  the  use  of  stimulants,  and  any  excitement  or  undue 
exercise  that  increases  the  heart's  action  may  also  cause  it.  It 
is  most  common  with  patients  who  bleed  excessively,  and  usually 
occurs  the  night  following  the  operation,  being  due  to  the  reac- 
tion, favored  by  the  recumbent  position  of  the  body.  This  is  the 
most  common  form  of  hemorrhage  with  which  the  operator  has 
to  deal. 

Treatment. — This  form  of  hemorrhage  is  usually  controlled  by 
packing  the  socket,  and,  when  carefully  done,  will  control  any 
case  of  post-extraction  hemorrhage  of  the  character  that  has 
come  under  the  observation  of  the  author.  Having  suitable  in- 
struments and  all  the  materials  in  readiness,  the  socket  is 
syringed  with  an  antiseptic  solution  to  remove  any  foreign  mate- 
rial or  blood  clot  that  may  be  present.  A  piece  of  plain  sterilized 
gauze,  which  has  been  previously  cut  to  a  suitable  size,  is  seized 
near  one  end  with  tweezers  and  quickly  carried  to  the  apex  of  the 
socket,  after  which  the  succeeding  portion  is  rapidly  pressed  into 
place  until  the  entire  area  is  tightly  packed  and  the  material  is 
flush  with  the  surface.  A  small  amount  of  sandarac  varnish  is 
applied  to  its  surface,  which  will  render  it  impervious  to  mois- 
ture. The  packing  is  held  in  position  for  a  short  time,  and  will 
usually  remain  where  placed  without  additional  support.  If  this 
procedure  does  not  properly  hold  the  packing,  it  may  be  retained 
by  placing  over  it  an  extra  piece  of  gauze  and  ligating  the  ap- 
proximating teeth  in  figure-eight  fashion,  with  the  ligature  cross- 


374  HEMORRHAGE 

ing  over  the  dressing;  or,  if  there  are  no  approximating  teeth,  the 
wound  may  be  sutured  by  carrying  a  ligature  through  the  labial 
and  lingual  gum  tissue  on  each  side  of  the  socket  and  tying  it 
over  the  packing.  Usually  one  suture  is  enough,  but,  where 
necessary,  a  second  one  may  be  used.  Another  method  of  reten- 
tion is  to  roll  a  cylinder  of  gauze  of  suitable  size,  place  it  on  top 
of  the  packing,  and  have  the  patient  close  the  mouth  so  as  to 
bring  the  opposing  arch  tightly  against  this  cylinder.  The  jaws 
must  be  held  in  the  one  position  after  they  are  closed,  and,  if  the 
patient  cannot  be  relied  on  to  do  this,  they  should  be  secured  by 
the  application  of  Barton's  bandage.  The  latter  method  of  re- 
tention is  preferred,  in  most  cases,  to  suturing,  and  is  indicated 
where  the  bleeding  is  from  more  than  one  socket. 

In  packing  the  sockets  of  a  multiple-rooted  tooth,  each  socket 
must  be  packed  separately,  and,  as  the  packing  is  a  rather  pain- 
ful operation,  every  possible  effort  should  be  made  to  effectually 
seal  the  wound  at  the  first  attempt.  If  preferred,  the  gauze  may 
be  dipped  into  powdered  alum  or  tannic  acid  before  introducing 
it  into  the  socket. 

Where  the  hemorrhage  is  severe  and  difficult  to  control,  and 
the  gauze  dressing  cannot  be  retained  in  the  socket  without  re- 
sorting to  the  methods  described  above,  a  plaster  of  paris  dress- 
ing is  advised.  Sterilized  gauze  is  saturated  with  the  plaster, 
which  has  been  mixed  to  a  medium  stiffness,  rolled  into  a  cone, 
and  firmly  pressed  into  the  socket,  being  held  there  until  it  has 
hardened  sufficiently  to  be  retained  in  position.  Or  the  socket 
may  be  filled  with  modeling  compound  that  has  been  softened  by 
heat,  being  chilled  into  hardness  after  it  is  in  place,  after  which 
it  is  withdrawn  and  coated  with  beeswax  or  plaster  of  paris, 
when  it  is  again  inserted  and  held  in  position  until  the  wax  or 
plaster  has  hardened.  This  form  of  packing  has  the  advantage 
of  completely  adapting  itself  to  every  part  of  the  socket,  thus 
effectually  sealing  every  opening  from  which  blood  may  escape, 
and  its  automatic  retention  obviates  the  necessity  of  suture  or 
bandage. 

There  is  a  variation  in  the  length  of  time  that  a  socket  should 
remain  packed.  In  most  cases  the  packing  can  safely  be  re- 
moved the  following  day,  while  in  some  cases  it  should  remain 
for  a  longer  period.  Where  the  alveolus  or  maxillary  tuberosity 
is  fractured,  and  it  is  necessary  to  control  the  hemorrhage  by  a 


INSTRUCTING  PATIENT  375 

tampon  of  antiseptic  gauze,  the  packing  may  be  left  in  the  wound 
for  a  greater  length  of  time  and  then  removed  with  care.  In 
some  cases  it  is  advisable  to  remove  only  a  i^ortion  of  the  gauze 
at  a  time,  cutting  off  the  part  that  is  removed. 

SECONDARY  HEMORRHAGE. 

This  form  of  hemorrliage  occurs  after  a  lapse  of  at  least 
twenty-four  hours  from  the  time  of  operating,  and  may  occur 
after  an  interim  of  several  days,  being  usually  due  to  sepsis  or 
infection. 

Treatment. — The  method  of  treating  intermediary  hemorrhage 
by  pressure  (page  373)  applies  also  to  secondary  hemorrhage. 
Preliminary  to  packing  the  socket,  the  wound  must  be  effectually 
cleansed.  All  broken-down  tissue  and  blood  clots  are  removed 
with  tweezers,  the  parts  carefully  syringed  with  an  antiseptic 
solution,  and,  where  there  is  considerable  putrefaction,  it  is  ad- 
visable to  touch  the  parts  with  a  strong  antiseptic.  In  secondary 
hemorrhage  the  dressing  should  never  be  allowed  to  remain 
longer  than  twenty-four  hours,  and  in  most  cases  should  be  re- 
moved in  from  ten  to  twelve  hours.  If  there  is  a  recurrence  of 
bleeding,  the  wound  is  again  cleansed,  treated  antiseptically,  and 
packed. 

INSTRUCTING  THE  PATIENT. 

After  an  extraction  where  there  is  excessive  bleeding  or  a 
tendency  to  hemorrhage,  or  after  a  post-extraction  treatment  for 
liemorrhage,  the  patient  should  be  instructed  to  abstain  from 
the  undue  use  of  stimulants,  avoid  excessive  exercise,  maintain 
an  upright  position  as  far  as  possible,  and  use  a  high  pillow  at 
night.  The  jaws  should  be  kept  at  rest,  and  hot  drinks  or  foods 
should  not  be  taken.  All  forms  of  excitement  should  be  avoided, 
and  any  fears  arising  from  a  former  hemorrhage  should  be 
allayed. 

Where  the  conditions  indicate  a  tendency  to  hemorrhage,  the 
suggestion  should  be  made  to  operate  in  the  morning,  for,  if  the 
hemorrhage  occurs,  it  can  receive  the  necessary  attention  during 
the  day,  or  the  wound  be  packed  immediately. 

Where  there  is  likely  to  be  an  oozing  of  blood  from  margins 
of  the  wound  for  some  time  after  the  operation,  it  is  advisable 


376  HEMORRHAGE 

to  explain  to  the  patient  that  a  very  small  quantity  of  blood 
will  discolor  a  large  amount  of  saliva,  and,  unless  there  is  quite 
a  flow  of  blood,  not  to  be  alarmed  at  the  apparently  excessive 
bleeding. 

EXCESSIVE  BLEEDERS. 

A  history  of  excessive  hemorrhage  following  a  previous  ex- 
traction should  be  carefully  noted  to  ascertain  whether  it  was 
caused  by  some  general  or  local  condition  or  by  a  tendency  to 
abnormal  bleeding.  Inquiry  may  indicate  constitutional  pre- 
disposing causes  to  hemorrhage,  such  as  diabetes,  albuminuria, 
chronic  interstitial  nephritis,  atheroma,  a  cardiac  or  jDulmonary 
trouble,  or,  if  a  woman,  to  ''vicarious  menstruation."  Local 
causes,  as  chronic  gingivitis  or  acute  inflammation,  may  have 
been  the  cause  of  the  former  trouble;  or  the  operation  may  have 
caused  considerable  laceration  of  the  tissues;  or  the  former  opera- 
tion may  have  been  regarded  very  lightly  on  the  part  of  the  pa- 
tient, and  followed  by  undue  exercise  or  careless  use  of  stimu- 
lants. Whatever  may  have  been  the  cause  of  the  hemorrhage 
on  a  former  occasion,  if  the  condition  still  exists,  or  the  appear- 
ance of  physical  condition  of  the  patient  indicates  excessive 
bleeding,  it  is  advisable  to  defer  the  operation,  and  administer 
calcium  lactate  in  15-grain  doses,  three  times  a  day,  for  a  few 
days  preceding  the  operation.  Tn  case  there  are  a  number  of 
teeth  to  be  removed,  the  mouth  may  be  cleansed,  one  of  the  teeth 
extracted,  and  the  results  awaited;  if  no  excessive  hemorrhage 
occurs,  the  remainder-may  be  removed  at  a  subsequent  time. 

Where  several  loose  teeth  are  to  be  extracted,  and  there  is 
profuse  bleeding  following  the  removal  of  one  of  the  teeth,  which 
sometimes  occurs,  it  is  preferable  to  remove  them  at  two  or  more 
sittings  than  to  subject  the  patient  to  an  unnecessary  loss  of 
blood. 

HEMOPHILIA. 

Hemophilia,  or  hemorrhagic  diathesis,  a  persistent  and  uncon- 
trollable tendency  to  bleeding,  even  from  slight  wounds,  is  con- 
genital and  hereditary,  and  the  family  history  in  these  cases  is 
always  interesting.  The  disease  is  transmitted  through  the 
females  to  the  males,  the  former  often  escaping  the  ailment.  The 
pathologic  cause  of  this  affection  has  not  been  discovered,  but 


HEMOPHILIA  377 

it  is  likely  associated  with  the  blood  itself,  and  not  with  the 
vessels,  which  are  apparently  normal. 

Treatment. — Hemophilia  will  usually  manifest  itself  early  in 
life  by  trifling  injuries  causing  extensive  bruises,  or  by  hemor- 
rhage into  the  joints,  resulting  in  their  swelling,  or  by  bleeding 
from  mucous  surfaces.  This  condition  is  rare,  but,  if  the  history 
indicates  its  probable  presence,  an  operation  should  not  be  per- 
formed without  a  thorough  investigation,  and,  when  present, 
the  simplest  extraction  should  not  be  performed  unless  condi- 
tions make  such  course  imperative.  Where  it  is  absolutely 
necessary  to  operate,  a  treatment  directed  toward  correcting 
the  constitutional  defect  should  be  instituted.  The  administra- 
tion of  calcium  lactate  in  10-  to  15-grain  doses,  three  times  a  day 
for  three  to  four  days  preceding  the  operation,  to  promote 
coagulation  and  the  formation  of  fibrin  in  the  blood,  is  recom- 
mended. The  removal  of  the  tooth  should  be  executed  with  a 
minimum  amount  of  laceration,  and  the  patient  be  carefully 
instructed  as  to  the  care  of  the  wound  and  personal  conduct  for 
several  days  following  the  operation. 

If  the  hemorrhage  is  severe,  it  may  produce  marked  constitu- 
tional effects  and  death  occur  suddenly  from  syncope,  but  such 
cases  rarely  occur  in  the  practice  of  exodontia.  These  grave 
effects  are  caused  as  much  by  the  rapidity  of  the  bleeding  as 
by  the  total  amount  of  blood  lost.  A  patient  can  better  sus- 
tain a  gradual  loss  than  a  sudden  escape  of  blood,  and,  as  the 
bleeding  following  an  extraction  is  usually  from  small  vessels,  a 
serious  hemorrhage  is  not  likely  to  occur  suddenly;  but,  if  such 
hemorrhage  does  take  place,  there  will  be  sufficient  time  to 
summon  medical  aid,  and  it  may  be  well  for  the  operator  to  refer 
to  works  on  general  surgery  for  systemic  treatment  by  trans- 
fusion, hypodermoclysis,  or  enema. 

If  a  hemorrhage  is  gradual,  but  continuous,  the  patient  may 
become  weak  and  actually  faint,  which  in  such  case  is  beneficial, 
as  the  occurrence  will  check  the  flow  and  promote  coagulation, 
and  the  greater  the  loss  of  blood,  up  to  one-half  of  the  required 
amount  of  blood  in  the  body,  the  more  coagulable  it  becomes. 
During  a  continuous  hemorrhage  the  blood  pressure  necessarily 
falls,  but,  unless  a  large  volume  is  lost — about  one-third  of  the 
entire  amount  in  the  body — the  pressure  quickly  rises  to  the 
normal  when  the  bleeding  ceases. 


CHAPTER  XVII. 
GENERAL  AND  LOCAL  ANESTHESIA. 

As  this  book  is  especially  devoted  to  presenting  the  subject  of 
extraction  of  teeth,  it  is  not  the  intention  to  give  extended  space 
to  the  discussion  of  anesthesia.  As,  however,  anesthesia  is  inti- 
mately connected  with  the  extraction  of  teeth,  being  a  most  valu- 
able adjunct  to  dental  surgery,  it  is  deemed  proper  that  a  brief 
summary  of  the  evolution  of  anesthetics  and  a  condensed  refer- 
ence to  the  most  approved  methods  of  inducing  anesthesia  be 
given,  with  the  realization  that  the  dental  practitioner  will 
prefer  to  consult  special  works  on  the  various  methods  of  induc- 
ing anesthesia  for  detailed  information  on  that  subject. 

There  are  two  kinds  of  anesthesia  and  two  classes  of  anes- 
thetics. The  two  kinds  of  anesthesia  are  general  and  local,  and 
the  two  classes  of  anesthetics  comprise  agents  that  are  used  to 
induce  respectively  general  and  local  anesthesia. 

GENERAL  ANESTHESIA. 

By  the  term  "general  anesthesia"  is  meant  a  condition  where 
a  patient,  by  inhaling  certain  chemical  agents  either  through 
the  mouth  or  nose,  or  simultaneously  through  both  mouth  and 
nose,  is  rendered  unconscious  and  insensible  to  pain.  This  con- 
dition is  caused  by  the  action  of  the  agent  on  the  central  nervous 
system,  the  different  agents  affecting  the  centers  of  respiration 
and  circulation  in  various  degrees  peculiar  to  their  properties. 

Early  writings  on  the  subject  of  surgery  bear  evidence  that 
the  ancients  endeavored  to  prevent  physical  pain  in  the  case  of 
a  patient  subjected  to  surgical  procedure.  To  produce  the  con- 
dition now  referred  to  as  anesthesia,  such  patient  was  rendered 
more  or  less  unconscious  and  insensible  to  pain  by  the  internal 
use  of  Indian  hemp,  the  juice  of  the  poppy,  a  preparation  of 
mandragora,  and  other  drugs  possessing  narcotic  properties,  by 
the  inhalation  of  the  fumes  of  Indian  hemp,  and  by  digital  com- 
pression of  the  carotid  arteries,  the  latter  method  causing  a 

378 


GENERAL  ANESTHESIA  379 

depletion  of  the  cerebral  circulation  and  consequent  stupefac- 
tion. Alcohol  in  various  forms  was  also  used  from  an  uncertain 
period  for  producing  a  condition  of  stupor  approximating  a  loss 
of  sensation. 

Ether  was  discovered  by  Valerius  C'ordus  in  1540,  and,  although 
Michael  Faraday  had  in  1818  referred  to  the  narcotic  effect  of 
ether,  its  anesthetic  j^roperty  in  general  surgery  was  not  discov- 
ered until  18-1-2  by  Dr.  Crawford  W.  Long,  a  physician,  at  Jack- 
son, Ga.  The  anesthetic  property  of  ether  in  dental  surgery  was 
determined  by  Dr.  William  T.  G.  Morton,  a  dentist,  at  Boston, 
Mass.,  in  1846.  Dr.  Morton  had  received  the  suggestion  of  the 
probable  efficacy  of  ether  as  an  anesthetic  in  dental  surgery  from 
Dr.  Charles  T.  Jackson,  a  physician,  of  Boston,  who  was  familiar 
with  practical  chemistry,  without  either  of  these  persons  being 
cognizant  of  the  fact  that  the  general  anesthetic  property  of 
ether  had  been  ascertained  four  years  previous  by  Dr.  Long,  and 
Dr.  Morton  was  credited  at  the  time  with  the  discovery  of  the 
anesthetic  property  of  ether,  which  credit  was  proper  so  far  as 
its  general  application  in  dentistry  was  concerned. 

When  Dr.  Morton  discovered  in  1846  the  general  anesthetic 
property  of  ether,  he  gave  it  the  name  "letheon,"  from  lethe,  a 
word  derived  from  the  Greek,  meaning  '^ oblivion,"  "loss  of 
memory,"  "unconsciousness."  Dr.  Oliver  Wendell  Holmes  sub- 
sequently suggested  the  name  "anesthetic,"  a  combination  of  two 
words  derived  from  the  Greek — an  (not)  and  esthetic  (to  per- 
ceive, to  feel) — indicating  the  literal  meaning  of  the  word  to  be, 
"no  perception,"  "no  feeling,"  or,  by  implication,  "no  sensa- 
tion." At  the  time  that  Dr.  Holmes  suggested  the  name  "anes- 
thetic" for  the  agent  he  also  supplied  the  name  "anesthesia" 
for  the  condition,  a  term  derived  from  the  same  source  as 
the  word  "anesthetic."  By  the  term  "general  anesthesia"  is, 
therefore,  understood  a  condition  where,  by  the  introduction  of 
certain  agents  into  the  system  by  inhalation,  the  mind  loses  con- 
sciousness and  insensibility  to  pain  is  established. 

Ethyl  chlorid  was  discovered  by  Bouelle  in  1759,  and,  although 
Pierre  Flourens  had  in  1847  referred  to  the  narcotic  effect  of 
ethyl  chlorid,  its  anesthetic  property  in  general  surgery  was  not 
discovered  until  a  year  later  (1848)  by  Heyfelder,  but  was  not 
recognized  as  a  general  anesthetic  until  1895. 

Nitrous  oxid  was  discovered  by  Joseph  Priestley  in  1776  by 


380  GENERAL  AND  LOCAL  ANESTHESIA 

the  action  of  nitric  acid  on  moist  iron  filings,  and  was  subse- 
quently prepared  by  Pierre  Laplace  and  after  him  by  Claude 
Berthollet  from  ammonium  nitrate,  the  source  of  the  nitrous  oxid 
in  use  at  the  present  time.  While  Humphry  Davy  had  in  1800 
observed  the  narcotic  effect  of  nitrous  oxid,  its  anesthetic  prop- 
erty in  dental  surgery  was  not  discovered  until  1844  by  Horace 
Wells,  a  dentist,  at  Hartford,  Conn. 

Chloroform  was  discovered  by  Dr.  Samuel  Guthrie,  at  Sackett's 
Harbor,  N.  Y.,  in  1831,  and  its  anesthetic  property  in  general 
surgery  was  discovered  by  Dr.  James  Y.  Simpson,  at  Edinburgh, 
Scotland,  in  1847. 

Mesmerism  was  introduced  in  1778  by  Mesmer,  a  German  phy- 
sician, who  had  previously  practiced  the  treatment  of  disease 
with  magnets.  Mesmerism  was  a  psychophysiologic  process  by 
which  a  person  could  be  placed  in  a  condition  of  somnolence, 
during  which,  it  was  claimed,  pain  could  be  averted  while  under- 
going a  surgical  operation.  This  condition  was  later  called 
hypnotism  by  Braid,  a  term  that  prevails  to  this  day  for  that 
effect. 

The  method  of  administering  ether  with  nitrous  oxid  was 
introduced  by  Clover  in  1876,  in  which  procedure  the  inhalation 
of  nitrous  oxid  preceded  that  of  ether,  so  that  the  patient  did 
not  experience  the  obnoxious  odor  and  irritating  effect  of  the 
latter. 

The  method  of  administering  nitrous  oxid  with  varying  quan- 
tities of  oxygen  to  obtain  a  nonasphyxial  form  of  anesthesia  was 
introduced  by  Dr.  E.  Andrews,  of  Chicago,  in  1868,  a  procedure 
that  improved  the  anesthetic  effect. 

The  chronological  order  of  the  discoveries  of  the  four  princi- 
pal anesthetic  agents  is:  ether,  1540;  ethyl  chlorid,  1759;  nitrous 
oxid,  1776;  chloroform.  1831.  The  chronological  order  of  discov- 
ering their  anesthetic  properties  is:  ether,  1842  (in  dental  sur- 
gery, 1846);  nitrous  oxid,  1844;  chloroform,  1847;  ethyl  chlorid, 
1848. 

It  appears  remarkable  that,  although  these  agents  were  used, 
soon  after  their  discovery,  for  chemical  and  experimental  pur- 
poses, and  in  the  case  of  ether  and  nitrous  oxid  served  also 
the  means  of  amusement,  their  anesthetic  properties  were  not 
known  until  quite  a  number  of  years  afterward.  For  example, 
the  anesthetic  property  of  ether  was  not  known  until  302  years 


GENERAL  ANESTHETICS  381 

after  its  discovery,  and  the  anesthetic  property  of  nitrous  oxid 
was  not  known  until  G8  years  after  its  discovery, 

Altliough  Dr.  Wells  received  his  suggestion  of  the  probable 
anesthetic  property  of  nitrous  oxid  while  attending  a  lecture  on 
chemistry  and  natural  philosophy  by  Dr.  Gardner  Q.  Colton,  at 
Hartford,  as  early  as  1844,  on  which  occasion  the  peculiar  mirth- 
ful effect  of  the  inhalation  of  nitrous  oxid  as  "laughing  gas"  was 
exhibited  for  the  amusement  of  the  audience,  and  Wells  at  once 
demonstrated  that  the  "gas"  did  possess  such  property,  it  was 
not  until  a  quarter  of  a  century  later  that  the  agent  was  gen- 
erally accepted  as  an  anesthetic  by  the  dental  profession.  The 
practical  adoption  of  nitrous  oxid  as  an  anesthetic  was  delayed 
until  1863,  when  Dr.  Colton,  becoming  convinced  by  numerous 
l^ractical  tests  of  the  efficiency  and  safety  of  the  agent  as  a  gen- 
eral anesthetic,  adopted  its  use  as  a  preventive  of  pain  in  the 
extraction  of  teeth,  and  by  1868  it  was  used  to  a  large  extent  by 
the  dental  profession.  Since  that  time  its  popularity  has  in- 
creased until  today,  with  the  improved  methods  for  its  adminis- 
tration, it  is  considered  the  safest  agent  known  for  general 
anesthesia. 

GENERAL  ANESTHETICS. 

The  agents  usually  employed  for  general  anesthesia  in  dental 
surgery  are  nitrous  oxid,  ether,  and  ethyl  chlorid,  and  these  may 
be  used  singly,  in  sequence,  or  in  various  combinations. 

Nitrous  Oxid. 

Composition. — Nitrous  oxid  (NoO)  is  prepared  from  ammo- 
nium nitrate  crystals  1)y  gradual  decomposition  with  heat.  The 
apparatus  for  preparing  nitrous  oxid  consists  of  a  porcelain-lined 
iron  retort,  with  which  is  connected  with  glass  tubes  a  series  of 
three  wash  bottles,  a  tube  from  the  last  bottle  connecting  with 
the  storage  tank.  The  three  wash  bottles  contain  respectively 
solution  of  ferrous  sulphate,  potassium  hydroxid,  and  a  weak 
solution  of  sulphuric  acid  or  milk  of  lime  for  the  purpose  of 
removing  impurities — ehlorin,  nitric  oxid,  ammonia,  etc. — from 
the  gas  and  to  dry  it.  The  ammonium  nitrate  crystals  are 
placed  in  the  retort  and  heat  is  applied,  the  ammonium  decom- 
posing at  about  392°  F.     One  pound  of  the  ammonium  nitrate 


382  GENERAL  AND  LOCAL  ANESTHESIA 

will  yield  about  thirty-two  gallons  of  nitrous  oxid  gas.  Nitrous 
oxid  is  a  colorless  gas,  and  has  an  agreeable  odor  and  a  slightly 
sweetish  taste.  The  preparation  of  nitrous  oxid  is  not  supposed 
to  be  undertaken  by  a  dental  practitioner  in  his  office  unless  he 
has  occasion  to  use  large  quantities,  as  it  can  be  readily  obtained 
from  dental  supply  houses  in  liquid  form  in  steel  cylinders  of 
various  sizes.  These  cylinders  are  painted  black  to  distinguish 
them  from  cylinders  of  similar  construction  containing  liquid 
oxygen,  which  are  painted  red. 

Effect  on  the  Organism. — Nitrous  oxid  is  the  most  satisfactory 
anesthetic  for  the  extraction  of  teeth.  When  nitrous  oxid  is 
properly  administered,  it  presents  no  elements  of  danger,  and 
there  is  a  rapid  return  to  consciousness,  with  no  unpleasant  after- 
effects. The  admixture  of  a  proper  proportion  of  oxygen  im- 
proves the  anesthesia,  and  also  permits  a  prolongation  of  an 
administration  of  the  anesthetic.  A  safe  and  rapidly  acting 
anesthetic  is  desired  for  brief  dental  operations. 

Nitrous  oxid  as  an  anesthetic  was  originally  administered 
with  varying  percentages  of  air,  but  experience  has  demon- 
strated that  the  admixture  of  pure  oxygen  instead  of  air  mate- 
rially changes  and  greatly  improves  the  anesthesia  produced. 
Nitrous  oxid  possesses  the  least  toxicity  of  any  agent  for  produc- 
ing general  anesthesia,  and  is  the  safest  anesthetic  used  by  either 
the  dental  or  medical  profession.  It  can  be  given  longer  and 
with  less  danger  than  any  of  the  other  general  anesthetics. 
Oxygen  improves  the  quality  of  the  blood  by  increasing  the  red 
corpuscles,  while  the  white  corpuscles  are  not  influenced,  and  is 
a  respiratory  and  cardiac  stimulant,  being  a  specific  in  asphyxial 
manifestations. 

The  rate  of  absorption  of  nitrous  oxid  and  oxygen  by  a  patient 
will  depend  on  the  temperature  and  pressure  of  the  gas,  tempera- 
ture of  the  blood,  and  rate  and  depth  of  respiration.  The  rate  of 
elimination  will  depend  on  the  freedom  of  the  air  tract  and  the 
depth  and  efficiency  of  respiration,  the  elimination  taking  place 
principally  through  the  pulmonary  blood  stream  and  respiratory 
tract. 

Nitrous  oxid  does  not  affect  the  blood,  and  for  this  reason  a 
patient  anesthetized  with  this  agent  has  a  higher  immunity  from 
shock  and  infection  than  one  to  whom  ether  has  been  adminis- 
tered.    There  is  no  post-anesthetic  effect  on  the  lungs  or  kidneys. 


GENERAL  ANESTHETICS  383 

and  in  fact  no  other  part  of  the  body  seems  to  be  subject  to  such 
effect.  Nitrous  oxid  does  not  cause  any  degenerative  changes  in 
the  cells  of  the  body,  and  does  not  produce  any  harmful  results 
in  any  organ  of  the  system  unless  there  has  been  improper 
technic  of  administration — such  as  administering  cold  or  impure 
gases,  or  inducing  and  maintaining  a  marked  degree  of  cyanosis 
— which  can  be  avoided. 

The  Patient. — The  operator  should  note  the  physical  condi- 
tion of  the  i3atient  in  order  to  determine  whether  he  is  robust 
or  anemic,  or  whether  he  has  good  general  health  or  presents 
symptoms  of  debility,  and  the  pulse  should  be  taken  to  test  its 
strength  and  regularity.  In  some  cases  it  may  be  advisable  to 
ascertain  whether  the  patient  is  under  the  effects  of  intoxicants, 
and  to  learn,  if  possible,  whether  he  is  addicted  to  a  drug  habit. 
If  there  is  any  doubt  as  to  the  patient  tolerating  the  adminis- 
tration of  the  anesthetic,  an  opinion  should  be  sought  of  the 
patient's  physician,  or  a  thorough  examination  should  be  made. 

The  age  of  a  patient  is  not  necessarily  an  important  factor  to 
be  considered  in  an  administration,  as  any  person  from  youth  to 
advanced  years,  if  not  affected  with  any  organic  trouble  and  not 
presenting  any  special  contraindication,  is  acceptable  for  nitrous 
oxid.  The  health  and  vigor  of  the  patient  are  more  important 
factors  than  the  matter  of  age.  Even  children,  when  controlla- 
ble, are  good  subjects,  and  for  them  only  a  brief  administration 
is  required  to  induce  comjDlete  anesthesia. 

Preliminaries. — The  apparatus  for  anesthetization  should  be  in 
perfect  working  order,  and  all  the  required  forceps  and  other 
accessories  be  within  convenient  reach,  although  not  exposed,  be- 
fore the  patient  is  seated  in  the  chair.  It  is,  of  course,  necessary 
for  the  operator  to  have  a  competent  lady  assistant,  who  should, 
in  addition  to  being  an  attendant,  be  familiar  with  the  manage- 
ment of  the  apparatus,  so  that  the  attention  of  the  operator  may 
not  be  distracted  during  the  extraction  movements. 

While  no  special  dietetic  regimen  is  required  for  a  patient  pre- 
vious to  anesthetization,  it  is  advisable  to  have  at  least  two  hours 
intervene  between  a  meal  and  the  administration  of  the  anes- 
thetic, as  there  is  a  tendency  for  the  nitrous  oxid  to  induce 
nausea  if  administered  shortly  after  a  meal. 

The  patient  should  be  seated  in  a  comfortable  position  well 
back  in  the  chair,  with  the  head  in  a  line  with  the  body.     The 


384  GENERAL  AND  LOCAL  ANESTHESIA 

muscles  should  be  thoroughly  relaxed,  and  there  should  be  no 
evidence  of  restraint. 

Previous  to  anesthetization  an  examination  of  the  mouth 
should  be  made,  not  only  to  locate  the  affected  tooth  or  teeth  to 
be  extracted,  but  also  to  note  any  abnormalities  that  may  be 
present.  The  duration  of  anesthesia  depends  on  the  type  of 
patient  and  the  amount  of  nitrous  oxid  inhaled,  and  any  number 
of  teeth,  if  not  presenting  any  special  difficulties,  may  be  ex- 
tracted under  a  single  administration  in  the  case  of  adults.  Chil- 
dren should  not,  however,  be  subjected  to  the  removal  of  a  large 
number  of  teeth  under  one  administration,  as  they  are  not  favor- 
able subjects  for  prolonged  anesthesia. 

After  an  examination  of  the  mouth,  the  prop  is  inserted,  and 
the  mouth  or  nose  piece  properly  adjusted.  A  cord  should  be 
fixed  to  the  prop,  with  the  end  of  the  cord  hanging  out  of  the 
mouth  and  fastened  in  such  way  as  to  prevent  the  prop  from 
falling  into  the  throat. 

The  Apparatus. — The  principal  requisite  to  obtain  satisfactory 
results  with  nitrous  oxid  and  oxygen  as  a  general  anesthetic  in 
dental  surgery  is  the  apparatus.  The  construction  of  the  appa- 
ratus should  be  as  simple  as  possible,  but  should  at  the  same  time 
be  so  arranged  as  to  meet  the  requirements  of  the  various  cases 
that  may  be  presented.  There  should  be  means  for  administer- 
ing nitrous  oxid  and  oxygen  through  the  mouth  and  nose  simul- 
taneously or  through  either  of  these  organs  sej^arately.  The  in- 
haler should  be  of  such  construction  that  any  variation  of  posi- 
tion of  the  patient's  head  will  not  interfere  with  administering 
the  anesthetic.  There  should  be  also  attachments  for  adminis- 
tering ether  in  sequence  or  combination,  and  the  arrangement 
should  be  such  that  oxygen  can  be  administered  alone  as  well  as 
in  combination  with  the  nitrous  oxid  or  ether.  An  apparatus 
embodying  the  features  mentioned  may  seem  somewhat  compli- 
cated to  the  uninitiated,  but  it  will  be  found  to  be  very  simple  in 
construction. 

Quite  a  number  of  apparatus  for  administering  nitrous  oxid 
and  oxygen  are  manufactured,  and,  without  making  any  invidi- 
ous comparisons  of  the  various  apparatus,  it  can  be  said  that 
either  the  Clark,  White,  or  Teter  apparatus  possesses  the  essen- 
tial features  for  satisfactorily  administering  nitrous  oxid  and 
oxygen.     The  latter  apparatus  consists  of  a  folding  base,  which 


GENERAL  ANESTHETICS  385 

supports  a  mixing  cbamber,  to  wliicli  are  attached  yokes  bearing 
two  nitrous  oxid  and  two  oxygen  cylinders.     On  top  of  the  mix- 
ing chamber  is  an  attachment  for  administering  ether,  consisting 
of  a  vohitilizing  chamber  and  ether  dropper.     The  dropper  is 
accurately  regulated  by  the  operator,  and  the  ether  allowed  to 
drop  upon  a  cone,  which  distributes  it  around  the  gauze  in  the 
volatilizing  chamber.     Air  passes  through  the  gauze,  taking  up 
the  ether,  which  then  passes  into  the  mixing  chamber.     This 
attachment  is  to  be  employed  when  it  is  desired  to  use  the  nitrous 
oxid   and   oxygen   as   a  preliminary  to  ether  anesthesia.     The 
patient  is  anesthetized  with  nitrous  oxid  and  oxygen,  and  grad- 
ually carried  under  the  effects  of  the  ether,  a  small  percentage 
of  oxygen  with  ether  being  considered  beneficial.     At  the  front 
of  the  mixing  chamber  is  the  vapor  warmer,  through  which  the 
gases  pass  before  reaching   the  inhaler.      The  vapor  warmer 
is  filled  with  water,  which  is  kept  hot  with  an  alcohol  lamp, 
and  the  gases  passing  through  the  warmer  are  heated  to  about 
180°  F.     This  temperature  of  the  agents  is,  of  course,  too  hot  to 
be  inhaled,  but,  as  they  pass  through  a  tube  four  feet  long,  they 
lose  their  temperature  to  such  an  extent  that  when  they  reach 
the  inhaler  their  temperature  is  about  90°  to  94°  F.     Connected 
"with  the  apparatus  is  an  attachment  by  the  means  of  which 
ether  can  be  mixed  with  nitrous  oxid  and  oxygen  in  percentages 
varying  from  1   to  18  percent.     This   attachment   consists   of 
valves  and  a  glass  jar  containing  ether,  and  by  an  arrangement 
of  the  valves  the  nitrous  oxid  and  oxygen  can  be  passed  around 
the  jar,  or  a  part  or  all  of  the  gases  can  be  passed  through  the 
jar.     By  the  proper  use  of  this  attachment  the  most  obstinate 
patient  to  anesthetization  can  be  completely  relaxed,  and  usually 
a  very  small  loercentage  of  ether  in  addition  to  the  nitrous  oxid 
and  oxygen  is  sufficient  to  produce  this  condition. 

The  tubing  leading  to  inhalers  is  constructed  with  a  view  of 
being  boiled,  as  this  is  the  best  method  for  its  sterilization.  The 
nitrous  oxid  bag  is  removable,  and  should  also  be  sterilized  by 
boiling.  As  the  process  of  rebreathing  is  generally  followed,  it 
is  of  the  utmost  importance  that  the  bag,  tubing,  and  inhaler  be 
sterilized,  and  boiling  is  the  most  practical  method  for  sterilizing 
these  articles. 

The  face  inhaler  consists  of  a  celluloid  form,  with  pneumatic 
rim,  and  is  supplied  with  expiratory  and  pressure  valves.     The 


386  GENERAL  AND  LOCAL  ANESTHESIA 

nasal  inhaler  is  much  smaller,  and  covers  only  the  nose.  By  the 
use  of  the  nasal  inhaler  a  patient  can  be  anesthetized  with  nitrous 
oxid  and  oxygen  unless  there  is  complete  nasal  obstruction,  and 
continual  anesthesia  can  be  maintained  indefinitely,  even  if  the 
patient  is  inhaling  and  exhaling  through  the  mouth. 

Technic  of  Administration. — In  order  to  obtain  the  best  results 
from  nitrous  oxid  and  oxygen,  the  method  of  administration 
should  be  carefully  studied  and  properly  conducted,  the  essential 
features  being,  in  addition  to  a  i)erfect  apparatus,  warm  gases, 
rebreathing,  continuous  and  even  flow  of  the  gases,  and  positive 
pressure.  The  necessity  for  warming  the  nitrous  oxid  is  that  the 
gas  becomes  very  cold  in  passing  from  the  liquefied  state  to  the 
gaseous  state.  The  advantages  of  administering  nitrous  oxid 
and  oxygen  in  a  warm  condition  are:  (1)  a  much  smaller  amount 
of  nitrous  oxid  is  required,  there  being  a  saving  of  from  one- 
third  to  one-half;  (2)  anesthesia  is  much  more  quickly  and 
quietly  induced;  (3)  a  more  tranquil  and  deeper  narcosis  is  pro- 
duced, as  a  greater  amount  of  the  gases  is  taken  up  by  the  blood ; 
(4)  the  irritating  effects  of  cold  vapors  on  the  resi^iratory  tract 
and  lungs  are  avoided,  thereby  i)reventing  the  occasion  of  post- 
anesthetic bronchitis  and  pneumonia. 

The  proper  amount  of  rebreathing  of  nitrous  oxid  is  to  be  gov- 
erned by  the  symptoms  of  each  patient.  A  robust,  active  patient 
will  tolerate  only  a  small  amount  of  rebreathing,  and  an  anemic, 
frail  patient  will  tolerate  a  large  amount  of  rebreathing.  An 
excessive  amount  of  carbon  dioxid  will  be  manifested  by  forced 
respiratory  efforts,  followed  by  sweating,  livid  color,  slowing  of 
pulse,  and  cessation  of  respiration.  Oxygen  is  added  to  prevent 
an  excess  of  carbon  dioxid,  and  fresh  nitrous  oxid  must  enter  or 
narcosis  will  become  light. 

When  the  supply  of  gases  is  so  arranged  that  an  even  flow  can 
be  obtained,  it  is  a  comparatively  simple  matter  to  induce  and 
maintain  an  even  narcosis.  The  nitrous  oxid  is  allowed  to  flow 
continually  during  the  administration,  the  amount  needed  de- 
pending on  the  type  of  patient,  and,  when  a  certain  amount  pro- 
duces the  desired  result  in  a  particular  case,  the  amount  need  not 
be  changed  throughout  the  entire  operation.  A  small  stream  of 
oxygen  should  also  be  flowing  during  the  administration,  and 
the  least  variation  in  the  flow  will  affect  the  narcosis.  An  even 
or  uneven  flow  of  the  oxygen  will  produce  a  corresponding  even 


GENERAL  ANESTHETICS  387 

or  uneven  anesthetic  state,  and,  in  fact,  a  successful  anesthesia 
will  depend  on  the  accurate  judgment  of  the  flow  of  oxygen. 

Signs  of  Anesthesia  and  Recovery. — ^Tlie  usual  signs  of  nitrous 
oxid  anesthesia  are:  (1)  color  slightly  dusky;  (2)  pupils  dilated; 
(3)  loss  or  impairment  of  conjunctival  reflex;  (4)  stertor,  or  deep, 
regular  breathing,  accompanied  by  soft  snoring;  (5)  jactitation 
— muscular  twitching  of  the  eyelids. 

The  return  to  consciousness  is  indicated  by  the  return  of  natu- 
ral color  of  the  patient's  face,  the  presence  of  voluntary  move- 
ments of  the  eyes,  and  reaction  of  the  pupil  to  light. 

Indications  and  Contraindications. — All  persons  not  afflicted 
with  any  organic  troul^le,  from  3"oung  adults  to  the  aged,  and 
children  of  a  controllable  temperament,  are  usually  good  sub- 
jects for  the  administration  of  nitrous  oxid.  In  the  case  of  the 
aged  it  is,  of  course,  necessary  to  carefully  observe  all  symptoms 
during  the  administration,  with  the  object  of  maintaining  a  natu- 
ral color  and  avoiding  excessive  blood  pressure,  as  the  effect  of 
the  anesthetic  is  very  rapid  in  these  cases.  Extreme  cyanosis 
should  not,  of  course,  be  produced  in  any  case  on  account  of  the 
greatly  increased  blood  pressure  that  accompanies  an  extreme 
cyanotic  condition. 

Patients  afflicted  with  slight  nasnl  obstructions,  or  even  hav- 
ing adenoids,  may  have  nitrous  oxid  administered,  as  a  flow  of 
the  agent  will  readily  pass  through  the  slightly  restricted  pas- 
sage. Patients  who  are  very  stout  are  not  good  subjects  for  gen- 
eral anesthesia,  as  they  rapidly  become  cyanosed  and  frequently 
suffer  from  shortness  of  breath. 

Female  patients  anesthetized  during  a  menstrual  period  are 
prone  to  excessive  hemorrhage  from  the  operation  wound,  and 
are  also  disposed  to  be  demonstrative  during  the  administration. 
Nitrous  oxid  may  be  administered  during  pregnancy,  but  in  the 
later  months  of  this  condition  sufficient  oxygen  must  be  admitted 
to  avoid  symptoms  of  asphyxiation.  It  is  not  advisable  to  ad- 
minister a  general  anesthetic  during  lactation,  as  the  secretive 
process  of  the  milk  may  be  impaired. 

Ethyl  Chlorid. 

Composition. — Ethyl  chlorid  (CJI-.Cl)  is  prepared  by  the 
action  of  hydrochloric  acid  on  a  boiling  solution  of  chlorid  of 
zinc  in  ethyl  alcohol.     Ethyl  chlorid  is  a  colorless,  mobile  liquid. 


388  GENERAL  AND  LOCAL  ANESTHESIA 

and  has  an  agreeable  odor.  It  is  very  volatile,  but  its  vapor  is 
heavier  than  air.  On  account  of  its  great  volatility,  it  should 
be  preserved  in  hermetically  sealed  glass  or  metallic  tubes  and 
kept  in  a  cool,  dark  place. 

Effect  on  the  Organism. — A  few  inhalations  of  the  vapor  of 
ethyl  chlorid  will  produce  a  feeling  of  pleasant  exhilaration,  and 
additional  inhalations  will  rapidly  cause  unconsciousness.  Ethyl 
chlorid  is  potentially  one  of  the  most  lethal  anesthetics,  and  has 
only  a  limited  field  of  usefulness  in  dental  surgery.  The  admin- 
istration of  ethyl  chlorid  requires  so  much  precaution,  and  its 
contraindications  are  so  numerous,  that  its  use  in  dental  opera- 
tions is  not  advised. 

Ether. 

Composition. — Ether  (C.H.O^O  is  prepared  from  ethylic  alco- 
hol by  a  process  of  dehydration  produced  by  the  action  of  sul- 
phuric acid.  Ether  is  a  colorless,  very  volatile  liquid,  and  has  a 
pungent  odor  and  burning,  sweetish  taste.  It  is  very  inflam- 
mable, and  should  l)e  kept  in  tightly  stoppered  bottles  in  a  cool, 
dark  phice. 

Effect  on  the  Organism. — Ether  is  a  powerful  cardiac  and  re- 
spiratory stimulant,  and  was  for  many  years  the  usual  anesthetic 
for  dental  operations  in  cases  where  a  longer  anesthetic  was  re- 
quired than  could  be  obtained  from  a  single  administration  of 
nitrous  oxid  gas.  In  the  course  of  time,  however,  the  methods 
of  prolonged  anesthesia  with  nitrous  oxid  were  perfected,  and 
ether,  for  the  purpose  of  general  anesthesia  in  dental  operations, 
is  now  used,  when  indicated,  only  in  conjunction  with  nitrous 
oxid  and  oxygen. 

Chloroform. 

Composition. — Chloroform  (CIICI3)  is  prepared  by  three 
methods — from  ethylic  alcohol,  from  methylated  spirit,  and  from 
acetone — and  is  usually  prepared  by  distilling  a  mixture  of  chlo- 
rinated lime  and  water  with  alcohol  or  acetone.  It  is  a  heavy, 
clear  liquid,  and  has  an  ethereal  odor  and  a  burning  taste. 
Chloroform  is  readily  volatilized,  but  its  vapor  density  is  four 
times  greater  than  air.  It  decomposes  readily  if  exposed  to  sun- 
light and  heat,  and  should  be  kept  in  a  cool,  dark  place. 


LOCAL  ANE8THESIA  389 

Effect  on  the  Organism. — Chloroform  posesses  extremely  lethal 
properties,  and  is  ]irone  to  affect  the  heart  action  and  cause 
cardiac  faihire.  The  preliminary  dietetic  regimen  that  is  usually 
necessary  hefore  an  administration  of  chloroform,  the  extreme 
precaution  to  he  ohserved  in  its  administration,  and  its  manj^ 
contraindications  render  it  unsuitahle  for  dental  operations. 

LOCAL  ANESTHESIA. 

By  the  term  ''local  anesthesia"  is  meant  a  condition  where, 
by  the  topical  a])])lication  of  certain  chemical  agents — either  by 
injection  or  application,  the  latter  being  direct  or  by  means  of  a 
spray — insensibility  to  pain  is  produced  in  a  circumscribed  area 
while  the  patient  is  in  possession  of  all  his  faculties,  in  which 
respect  the  method  differs  from  ''general  anesthesia,"  where 
complete  unconsciousness  supervenes  for  the  purpose  of  obtain- 
ing insensibility  to  pain  at  the  affected  part. 

In  addition  to  obtaining  local  anesthesia  by  injection  and 
application,  a  local  anesthetic  effect  can  be  produced  by  pres- 
sure, but  this  method  of  anesthesia  is  not  applicable  to  tooth 
extraction. 

While  it  is  recorded  that  the  ancients  endeavored  by  various 
methods  to  prevent  pain  during  surgical  operations,  it  seems 
that  their  efforts  to  attain  this  object  were  directed  more  toward 
general  than  local  anesthesia,  although  there  is  some  evidence 
that  the  inunction  of  various  narcotics  was  practiced  for  the 
purpose  of  obtaining  a  local  anesthetic  effect. 

Up  to  the  beginning  of  the  year  1800  no  definite  method  had 
been  developed  for  inducing  local  anesthesia,  but  about  this  time 
James  Moore  announced  that  an  obtunded  area  could  be  pro- 
duced by  compressing  nerve  trunks  as  well  as  by  severing  them. 

In  1856  Richet  discovered  that  local  anesthesia  could  be  pro- 
duced by  the  evaporation  of  ether,  but  at  that  time  no  apparatus 
had  been  devised  for  ]n'operly  conducting  this  procedure. 

In  1866  Sir  Benjamin  AV.  Richardson  had  fair  success  in  ob- 
taining local  anesthesia  with  ether  spray,  a  method  that  was  sub- 
sequently improved  and  is  used  to  a  limited  extent  at  the  present 
time. 

In  1855  Gadeke  isolated  the  alkaloid  now  known  as  cocain 
from  the  leaves  of  orythroxylon  coca,  and  was  ])y  him  called 
ethroxvlene. 


390  GENERAL  AND  LOCAL  ANESTHESIA 

In  1859  Niemann,  who  had  been  hivestigating  the  properties 
of  the  coca  plant,  observed  that  the  leaves  produced  a  numbness 
of  the  tongue  when  applied  to  that  organ. 

In  1874  Hughes  Bennett,  who  had  been  experimenting  with 
cocain,  demonstrated  that  it  possessed  anesthetic  properties. 

In  1880  Von  Anrep,  after  carefully  investigating  the  action  of 
the  drug,  intimated  that  it  might  be  prepared  in  such  manner  as 
to  be  used  as  a  local  anesthetic  in  general  surgery. 

In  1884  Roller,  who  had  prosecuted  a  series  of  experiments 
with  cocain  on  animals,  demonstrated  the  extraordinary  anes- 
thetic property  of  cocain,  and  its  injection  for  local  anesthesia 
on  the  body  surface  and  in  the  oral  cavity  became  at  once  very 
popular.  The  method  of  application  of  the  drug  and  its  effect 
were  not,  however,  sufficiently  understood  at  the  time,  when  it 
was  injected  pure  near  the  seat  of  the  irritation,  and  frequently 
unfortunate  results  followed  the  application. 

In  1885  Halstedt  introduced  the  method  of  conductive  anes- 
thesia (or  regional  anesthesia),  l)y  which  ]irocedure  cocain  was 
injected  at  the  trunk  of  the  inferior  dental  nerve  instead  of  in 
the  immediate  area  of  the  affected  tooth. 

Although  the  positive  anesthetic  property  of  cocain  was 
readily  admitted  and  appreciated,  its  toxicity  was  at  the  same 
time  realized  to  be  of  such  excessively  diffusive  strength  that 
some  method  for  its  modification  or  an  acceptable  substitute 
became  a  study  of  the  scientists  interested  in  the  development 
of  practical  local  anesthesia. 

In  the  efforts  that  were  subsequently  made  to  discover  a  substi- 
tute for  cocain  that  would  possess  equal  anesthetic  power  without 
its  toxicity,  such  agents  as  eucain  (alpha  and  beta),  acoin,  holo- 
cain,  tropacocain,  orthoform,  nirvarin,  stovain,  novocain,  alypin, 
and  others  were  developed  and  presented  with  the  expectation 
that  they  would  meet  the  requirements. 

Braun,  in  his  efforts  to  ascertain  the  specific  action  of  the 
various  cocain  substitutes  on  the  tissues,  found  that  the  simul- 
taneous vascular  contraction  at  the  seat  of  injection  increased 
the  intensity  and  duration  of  the  anesthesia  produced,  and  cor- 
respondingly reduced  the  amount  of  the  anesthetic  required  for 
any  particular  case,  without  impairing  its  effectiveness.  It  was 
this  discovery  that  prompted  him  to  mix  a  suprarenal  prepara- 
tion with  the  anesthetic  when  making  the  injection.     The  solu- 


LOCAL  ANESTHESIA  391 

tions  of  the  powdered  suprarenal  extract,  made  from  the  supra- 
renal glands  of  the  sheep  and  ox,  and  known  under  the  names  of 
suprarenin,  adrenalin,  renoform,  etc.,  have  the  property  of  ac- 
tively contracting  the  blood  vessels,  and,  when  mixed  with  cocain 
or  any  adaptable  substitute,  have  the  effect  of  checking  the 
diffusion  of  the  anesthetic  at  the  seat  of  the  injection,  thereby 
locally  intensifying  the  action  of  the  anesthetic  and  at  the  same 
time  avoiding  any  organic  disturbance.  Suprarenin  is  now  also 
prepared  synthetically,  and  is  said  to  be  purer,  less  toxic,  and 
more  stable  than  the  organic  preparation. 

In  local  anesthesia  there  is  produced  either  mucous  or  conduc- 
tive anesthesia.  In  mucous  anesthesia  only  the  terminal  rami- 
fications of  the  nerves  in  a  definite  area  are  affected,  and  the 
nerve  endings  are  for  a  certain  length  of  time  incapacitated  from 
receiving  impressions.  In  conductive  anesthesia  a  larger  nerve 
trunk  is  intercepted  directly  at  its  base,  and  is  prevented  from 
conducting  an  impression. 

In  the  administration  of  local  anesthesia  it  is  necessary  to  have 
a  knowledge  of  the  sensibility  and  nerve  supply  of  the  different 
tissues.  The  mucosa,  periosteum,  pericementum,  as  well  as  the 
juilp  and  dentin,  are  more  sensitive  to  pain  than  the  muscles,  and 
the  various  degrees  of  sensitiveness  of  these  parts  should  be  un- 
derstood. 

The  operator  should  be  familiar  with  the  technical  methods 
of  preventing  pain  by  injection  anesthesia,  and  should  know  the 
pharmacologic  and  physiologic  properties  of  the  solution  to  be 
used.  He  should  be  able  to  determine  the  general  physical  con- 
dition of  a  patient  in  order  to  treat  him  according  to  his  peculiar 
requirement.  Anemic,  feeble,  and  hysterical  patients  should  re- 
ceive special  attention,  and  the  dose  of  the  solution  lessened  in 
their  case  to  correspond  with  their  degree  of  toleration.  The 
pulse  and  respiration  should  be  carefully  observed,  so  that  any 
untoward  symptoms  may  be  recognized  and  counteracted  by  the 
necessary  change  in  the  procedure. 

Besides  realizing  the  importance  of  general  health,  the  opera- 
tor has  to  consider  the  local  condition  of  the  diseased  area,  which 
frequently  determines  the  correct  selection  of  the  method  to  be 
employed  for  the  prevention  of  pain. 

Local  anesthesia  of  the  mucosa  frequently  causes  severe  pain 
on  insertion  of  the  needle  and  during  injection  if  pericementitis 


392  GENERAL  AND  LOCAL  ANESTHESIA 

or  alveolar  necrosis  is  present,  and  the  operation  under  those 
conditions  is  usually  distressing  to  the  patient  and  annoying  to 
the  operator.  Special  care  should  be  taken  in  injection  anes- 
thesia to  maintain  asepsis  in  all  the  affected  parts,  as  this  is 
necessary  to  insure  a  normal  condition  of  the  tissues  after  the 
operation. 

LOCAL  ANESTHETICS. 

As  previously  stated,  the  great  anesthetic  property  of  cocain 
was  immediately  recognized  on  its  introduction  to  the  profession, 
but  the  deleterious  effect  of  the  undiluted  drug  on  the  organism 
was  of  such  a  nature  that  some  modificatiou  of  its  strength  or  a 
substitute  was  eagerly  sought.  Both  a  modification  of  cocain 
and  a  number  of  substitutes  have  been  found.  Of  the  number 
of  substitutes  that  have  been  formulated,  novocain  is  the  most 
acceptable  as  a  practical  injection  anesthetic. 

The  local  anesthetics  used  at  the  present  time  are  organic 
chemical  combinations  that  are  applied  either  on  the  mucosa  or 
injected  into  the  tissues  in  properly  proportioned  solutions.  For 
mucous  surface  anesthesia  a  high  percentage  cocain  solution 
or  a  concentrated  novocain  solution  is  used,  and  for  injection 
into  the  tissues  a  dilute  solution  of  either  of  these  agents  is 
employed.  In  the  application  on  the  mucosa  the  lymphatics 
take  up  the  salts  of  the  solution  as  tlie}^  penetrate  the  surface, 
and  carry  the  anesthetic  effect  to  underlying  tissue. 

The  essential  properties  of  an  effective  and  satisfactory  local 
anesthetic  are:  (1)  its  toxicity  must  not  exceed  the  degree  of 
toleration;  (2)  it  must  not  cause  any  tissue  lesion;  (3)  it  must 
be  soluble  in  water,  and  its  solution  must  be  sterilizable;  (4)  it 
must  combine  with  suprarenal  preparations. 

Of  no  less  importance  than  the  anesthetic  are  the  injection 
syringe  and  its  accessories.  There  are  different  makes  of 
syringes  to  be  had,  with  varying  claims  of  efficiency,  but  the 
essential  features  of  a  ])ractical  instrument  are  perfect  adjust- 
ment and  ease  of  operation.  While  all  the  parts  should  fit  accu- 
rately to  prevent  the  escape  of  fluid,  these  parts  should  be  easily 
removable,  so  that  they  can  be  thoroughly  sterilized,  especially 
by  boiling,  as  absolute  asepsis  must  be  preserved  in  all  parts 
of  the  syringe  in  order  to  avoid  the  possibility  of  infecting  the 
anesthetized  area. 


LOCAL  ANESTHETICS  393 


Cocain. 


Cocain  is  tlie  original  injection  anesthetic  for  local  anesthesia, 
but  on  account  of  the  excessive  toxicity  it  has  been  found  neces- 
sary to  reduce  its  toxic  effect  in  order  to  make  it  a  practical 
anesthetic.  This  has  been  done  by  using  it  in  dilute  form  and 
with  the  addition  of  suprarenin  (suprarenal  extract),  the  latter 
having  the  therapeutic  action  of  causing  the  constriction  of  the 
blood  vessels  and  thereby  producing  a  high  local  blood  pressure. 
The  admixture  of  suprarenin  thus  prevents  too  rapid  absorption 
of  the  anesthetic  and  jDrolongs  the  anesthesia. 

The  injection  of  the  anesthetic  into  the  mucosa  infiltrates  the 
tissue  area  surrounding  the  point  of  injection,  and  has  the  effect 
of  paralyzing  the  functions  of  the  nerves  supplying  the  area  to 
such  an  extent  that  an  insensibility  to  pain  is  established.  The 
paralyzation  takes  place  within  from  two  to  ten  minutes,  de- 
pending on  the  strength  of  the  solution  employed,  and  lasts 
about  half  an  hour,  when  the  eifect  gradually  subsides. 

The  technic  of  injection  involves  so  many  features — the  man- 
ner of  inserting  the  needle  varying  to  some  extent  with  the  differ- 
ent teeth,  and  governed  also  by  the  physical  condition  of  the 
parts  affected,  including  the  exercise  of  great  care  not  to  punc- 
ture an  artery — that  the  space  required  for  a  comprehensive 
discussion  of  the  technic  would  be  too  great  for  a  place  in  this 
book,  and  the  practitioner  and  student  are  therefore  referred 
for  detailed  information  on  this  matter  to  special  works  on 
this  subject. 

Novocain. 

Of  all  the  substitutes  for  cocain  so  far  discovered,  novocain  is 
the  most  suitable  agent  for  local  anesthesia  in  dental  surgery. 
It  has  the  same  effective  action  on  the  peripheral  sensory  nerves 
as  cocain,  without  the  toxicity  of  the  latter,  and,  with  a  proper 
admixture  of  suprarenin,  makes  an  ideal  local  anesthetic.  As 
manufacturers  are  now  furnishing  a  correctly  proportioned  prep- 
aration of  these  agents,  known  as  novocain-suprarenin  mixture, 
it  can  be  conveniently  and  effectively  applied  with  satisfactory 
results.  The  same  observation  as  to  the  technic  of  injection  of 
cocain,  made  above,  applies  to  the  injection  of  novocain. 


394  GENERAL  AND  LOCAL  ANESTHESIA 


Freezing. 

Anesthesia  by  freezing  is  a  process  of  depriving  the  tissues  of 
as  much  heat  as  possible  by  the  application  of  a  congealing 
agent,  and  the  ether  chlorid  spray  is  the  method  usually  used  for 
this  purpose.  The  ethyl  chlorid  is  supplied  in  glass  and  metal 
tubes,  with  stop  cocks  by  which  the  operator  can  regulate  the 
amount  required. 

After  the  preliminary  preparations  have  been  made,  the  spray 
is  directed  against  the  prescribed  area,  and  the  ethyl  chlorid  gas 
that  is  generated  when  the  spray  comes  in  contact  with  the  warm 
surface  of  the  mucous  membrane  penetrates  the  epithelial  reti- 
form  interstices,  tissue  pores,  and  glands,  this  condition  being 
accelerated  by  the  high  pressure  caused  by  the  elimination  of 
heat.  The  parts  subjected  to  the  process  become  frozen  and 
turn  white,  having  the  effect  of  making  the  nerves  in  the  frozen 
area  insensible  to  pain.  As  it  is,  however,  difficult  to  properly 
direct  the  spray  on  the  posterior  part  of  the  mouth,  the  applica- 
tion of  this  method  is  practically  confined  to  the  anterior  teeth. 


INDEX 


Abscess,  acute  alveolar,  361 
alveolo-dental,  361 
cavity,  forcing'  tooth  into,  339 
dento-alveolar,  361 
Abscessed  teeth  as  counterindication  to  op- 
erating, 75 
tooth,  radiograph  for,  90 
Abutment,  examining-  bridge,  85 

extracting  bridge,  330 
Accessories,  toilet,  60 
Accident,  teeth  displaced  by,  347 

teeth  loosened  by,  347 
Accidents,  332 
Acute  alveolar  abscess,  361 
septic  pericementitis,  361 
suppurative  alveolitis,  361 
Adjacent  teeth,  bicuspid   roots  wedged  be- 
tvi^een,  216 
examining.  80,  85 
tooth,  disturbing  treatment  in,  343 
extraction  of,  338 
loosening,  342 
Administration  of  nitrous  oxid,  technic  of, 

386 
Advising  patient  before  operation,  103 
Allen  mouth-gag,  49 
Alveolar  abscess,  acute,  361 

application  of  forceps  to  inferior  bicus- 
pids, 208 
of  forceps  to  inferior  cuspids,  200 
of  forceps  to  inferior  first  and  second 

molars,  225 
of  forceps  to  inferior  incisors,  189 
of  forceps  to  inferior  third  molar,  266 
of  forceps  to  superior  bicuspids,  144 
of  forceps  to  superior  central  incisor, 

111 
of  forceps  to  superior  cuspid,  130 
of  forceps   to   superior   first  and  sec- 
ond molars,   158 
of  forceps  to  superior  lateral  incisors, 

122 
of  forceps  to  superior  third  molar,  174 
complete,    impacted    superior   third    mo- 
lar, 181 
partial,   impacted   superior   third  molar, 

179 
process,  examining,  86 
exposed,  355 

extensive  fracture  of,  353 
fracture  of,  337 
fractured  margin  of,  352 
irregular  margin  of,  352 
loose  spicula  of.  352 
sharp  margin  of,  352 
traumatic  injury  to,  352 
Alveolitis.  359 

acute  suppurative,  361 
post-operative.  361 
Alveolo-dental  abscess,  361 
Alveolus,  radiograph  for  fracture  of,  91 
Anatomical  landmarks,  63 

import  of.  69 
Anatomy  of  deciduous  teeth.  316 
Anesthesia,   contraindications  for  nitrous 
oxid.  387 
general,  378 
historv  of  general,  378 
history  of  local.  389 
hypnotism  in  general,  380 
indications  for  nitrous  oxid.  387 
local,  378.  389 
local  conductive,  391 


Anesthesia — Cont'd. 
local  mucous.  391 
local  regional,  390 
mesmerism  in  general,  380 
patient  for  nitrous  oxid,  383 
preliminaries  for  nitrous  oxid,  383 
signs  of  nitrous  oxid,  387 
signs  of  recovery  from  nitrous  oxid,  387 
Anesthetic,  cocain  as  local,  393 

for  complete  impaction  of  inferior  third 

molar,  298 
for  deciduous  teeth,  317 
for  partial    impaction    of    inferior    third 

molar.  288 
fracture  under  general,  334 
freezing  as  local,  394 
novocain  as  local,  393 

property  of  chloroform,  discovery  of,  380 
of  ether,  discovery  of,  379 
of  ethyl  chlorid,  discovery  of,  379 
of  nitrous  oxid.  discovery  of,  380 
Anesthetics,  local,  392 
Ankylosis,  temporary,  106 

as  counterindication  to  operating,  75 
Anterior  teeth,  forceps  for  ten  inferior,  16 
roots  of,  68 

special  forceps  for  ten  superior,  22 
supplementary  forceps  for  inferior,  21 
Apollo,  forceps  in  temple  of,  1 
Apparatus,  nitrous  oxid,  59 

nitrous  oxid  and  oxygen,  384 
Application,  alveolar,   of  forceps  to  inferior 
bicuspids,  208 
of  forceps  to  inferior  cuspid,  200 
of  forceps  to  inferior  first  and  second 

molars,  225 
of  forceps  to  inferior  incisors,  189 
of  forceps  to  inferior  third  molar,  266 
of  forceps  to  superior  bicuspids.  144 
of  forceps  to  superior  central  incisor, 

111 
of  forceps  to  superior  cuspid,  130 
of  forceps  to  superior  first  and  second 

molars,  158 
of  forceps  to  superior  lateral   incisor, 

122 
of  forceps  to  superior  third  molar,  174 
labial,  of  curved-shank  elevator,  31 
lingual,  of  curved-shank  elevator,  31 
of  forceps  to  inferior  bicuspids.  208 
of  forceps  to  inferior  cuspid.  199 
of  forceps    to    inferior    first    and   second 

molars.  225 
of  forceps  to  inferior  incisors,  188 
of  forceps  to  inferior  third  molar.  266 
of  forceps  to  superior  bicuspids,  144 
of  forceps  to  superior  central  incisor.  111 
of  forceps  to  superior  cuspid.  130 
of  forceps  to    superior    first   and    second 

molars,  158 
of  forceps  to  superior  lateral  incisor.  122 
of  forceps  to  superior  third  molar,  174 
Approximating  space,  examining.  85 

tooth,  superior  third  molar  impacted  by, 
182 
Artificial  complications,  328 

hypercementosis  and,  323 
dentures  that  indicate  extraction,  72 
light,  59 

restorations,  disturbing,  342 
Attendant.  62 

Attitude    of   operator   for   deciduous    teeth, 
317 
of  operator  when   making   examination, 
77 


395 


396 


INDEX 


Author's  improved  lower  molar  forceps,  27 
improved  Standard  forceps  No.  7,  27 
lower  root  elevator,  33 

holding-,  35 
modified  Cryer  elevator,  41 

Lecluse  elevator,  3S 
special  elevator,  35 

B 

Bicuspid  roots,  149,  215 

covered  by  gum  tissue,  215 

wedged  between  adjacent  teeth,  216 
Bicuspids,  application    of   forceps    to    supe- 
rior, 144 

application  of  forceps  to  inferior,  208 

alveolar  application  of  forceps   to  infe- 
rior, 208 

alveolar  application  of  forceps  to  supe- 
rior, 144 

buccal  displacement  of  superior,  148 

caries  of  inferior,  212 

complete    buccal    displacement    of    infe- 
rior, 212 

complete   lingual   displacement   of  infe- 
rior. 210 

displacement  of  inferior,  210 

displacement  of  superior,  146 

elevator  for  superior,  152 

extensive  caries  of  superior,  149 

extraction  movements  for  inferior,  210 

extraction  movements  for  superior,  144 

forceps  for  inferior,  206 

forceps  for  superior,  11,  140 

fracture  of  inferior,  219 

fracture  of  superior,  152 

impacted  inferior,  218 

impacted  superior,  152 

inferior  first  and  second,  204 

lingual  displacement  of  superior,  146 

order  of  extraction  for  inferior,  208 

order  of  extraction  for  superior,  144 

partial  displacement  of  inferior,  212 

position  of  operator  for  inferior,  204 

position  of  operator  for  superior,  140 

position  of  patient  for  inferior,  204 

position  of  patient  for  superior,  140 

screv^^-porte  for  inferior,  218 

screw-porte  for  superior,  151 

superior  first  and  second,  140 

supernumerary  teeth  near  superior,  321 
Bismuth  syringe,  48 
Bleeders,  excessive,  376 

Bodies,  removing  foreign,  preceding  exam- 
ination, 79 

removing  foreign,  preceding  operation, 
79 
Breaking  an  instrument,  343 
Bridge  abutment,  examining,  85 
extracting,  330 

extracting  tooth  below,  331 

radiograph  for  root  below,  90 
Bruising  the  cheek,  344 

the  lip,  343 
Buccal  dento-osseous  structures,  64 

displacement,   complete,    of   inferior   bi- 
cuspids, 212 
complete,  of  inferior  third  molar,  270 
of  superior  bicuspids.  148 

partial,    displacement    of   inferior    third 
molar,  272 


Cabinet,  57 
Care  of  patient.  61 

Caries  above   gingival   margin   of  superior 
central  incisor,  115 
examining  tooth  attacked  by,  82 
examining  tooth  free  of,  81 
extensive,  of  inferior  cuspid,  202 
of  inferior  third  molar.  272 
of  superior  bicuspids,  149 
of  superior  central  incisor,  115 
of  superior   first   and   second   molars, 

163 
of  superior  lateral  incisor,  126 


Caries — Cont'd. 

gingival,  of  superior  third  molar,  176 
of  inferior  bicuspids.  212 
of  inferior  first  and  second  molars,  229 
of  superior  central  incisor,  115 
of  superior  cuspid,  138 
of  superior  first  and  second  molars,  162 
of  superior  third  molar.  176 
Carious  inferior  second  molar  isolated,  248 
Carrier,  foil,  54 

Cases,  surgical,  that  indicate  extraction,  72 
Causes  of  fracture  of  teeth.  332 
Cavity,  forcing-  tooth  into  abscess.  339 
Central  incisor,  alveolar  application  of  for- 
ceps to  superior,   111 
application  of  forceps  to  superior.  Ill 
caries  above    gingival    margin    of    supe- 
rior, 116 
caries  of  superior,  115 
chisel  for  superior,  118 

complete    labial    displacement    of    supe- 
rior. 114 
complete  lingual   displacement  of  supe- 
rior,  114 
displacement  of  superior.  114 
elevator  for  superior.  118 
extensive  caries  of  superior,  115 
extraction  movements  for  superior,  112 
forceps  for  superior,  10.  110 
fracture  of  superior.  118 
order  of  extraction  for  superior.  Ill 
partial  displacement  of  superior.  114 
position  of  operator  for  superior.  108 
position  of  patient  for  superior,  108 
root,  reinforcing  superior,  119 
superior,  116 

superior,  covered  by  gum  tissue,  116 
rotated  superior,  115 
screw-porte  for  superior,  118 
split  root  of  superior,  116 
superior,  108 
Chair,  operating,  57 

Checked  enamel,  examining  tootli  with,  82 
Cheek.  Ijruising  the,  344 
Child,  position  of  operator  when  operating 

on.  99 
Chisel  for  superior  central  incisor.  119 

mastoid,  53 
Chloroform,  388 

composition  of,  388 
discovery  of.  380 

discovery  of  anesthetic  property  of.  380 
effect  of,  on  the  organism.  389 
Chronic  septic  pericementitis.  365 
Clironological  development.  2 
Cocain  as  local  anesthetic.  393 
Comparative  list  of  forceps,  22 
Complete  alveolar  impacted  superior  third 
molar,  181 
buccal    displacement    of    inferior    bicus- 
pids. 212 
of  inferior  third  molar,  270 
impaction  of  inferior  third  molar,  296 
anesthetic  for.  298 
by  insufficient  space,  300 
by  malformation,  302 
by  osseous  tissue,  299 
by  soft  tissue,  299 
radiograpliic  diagnosis  of.  296 
labial    displacement    of    inferior    cuspid, 
200 
of  inferior  incisors,  192 
of  superior  central  incisor,  114 
of  superior  cuspid.  136 
of  superior  lateral  incisor,  125 
lingual   displacement   of   inferior   bicus- 
pids, 210 
of  inferior  cuspid,  200 
of  inferior  incisors.  192 
of  inferior  third  molar.  268 
of  superior  central  incisor,  114 
of  superior  cuspid,  136 
of  superior  lateral  incisor,  124 
Complications,  artificial.  328 
extraction  without,  349 
hypercementosis  and  artificial,  323 
Composition  of  chloroform,  388 


INDEX 


397 


Composition — Cont'd. 
of  ether,  388 
of  ethyl  chlorid,  387 
of  nitrous  oxid,  381 

Conditions,  pathologic,  that  indicate  extrac- 
tion, 70 
positions  for  various,  98 
that  do  not  indicate  extraction,  73 
that  indicate  extraction,  70 

Conductive  anesthesia,  local,  391 

Contraindication,  abscessed  teeth  as,  to  op- 
erating", 75 
epilepsy  as,  to  operating,  76 
heart  lesion  as,  to  operating,  75 
hemorrhagic  diathesis  as,    to   operating, 

76 
pregnancy  as,  to  operating,  76 
temporary  ankylosis  as,  to  operating,  75 

Contraindications    for    nitrous    oxld    anes- 
thesia, 387 

Counterindications  to  extraction,  70 
to  operating,  74 

Crown,    examining   root   supporting    dowel, 
8  5 
examining  root  supporting  shell,  84 
examining  tooth  writh  fractured,  81. 
extracting  root  supporting  dowel,  328 
extracting  tootli  supporting  shell,  329 
of  inferior  third  molar  distally  inclined, 

272 
peg-shaped,  of  svipernumerary  tooth,  320 

Cryer  elevator,  38 

author's  modified,  41 

Curet,  49 

Curved  scissors,  47 

Curved  shank  elevator,  30 
labial  application  of,  31 
lingual  application  of,  31 

Cuspid,  alveolar    application    of   forceps    to 
inferior,  200 
alveolar  application  of  forceps  to  supe- 
rior, 130 
application  of  forceps  to  inferior,  199 
application  of  forceps  to  superior,  130 
caries  of  superior,  138 

complete    labial    displacement    of    infe- 
rior, 200 
of  superior.  136 
complete   lingual   displacement   of   infe- 
rior, 200 
of  superior,  136 
displacement  of  inferior,  200 
displacement  of  superior,  136 
extensive  caries  of  inferior,  202 
extraction  movements  for  inferior,  200 
extraction  movements  for  superior,  133 
forceps  for  inferior,  196 
forceps  for  superior,  10,  129 
fracture  of  superior,  140 
impacted  inferior,  203 
impacted  superior, 137 
inferior,  196 

order  of  extraction  for  inferior,  198 
order  of  extraction  for  superior,  130 
partial  displacement  of  inferior,  202 
partial  labial    displacement   of   superior, 

137 
partial  lingual  displacement  of  superior, 

137 
position  of  operator  for  inferior,  196 
position  of  operator  for  superior,  129 
position  of  patient  for  inferior,  196 
position  of  patient  for  superior,  129 
root,  superior,  139 
superior,  129 

Cuspids,  deciduous  inferior,  318 

Cuspidor,  fountain,  58 

D 

Day,  time  of,  for  operating,  103 
Deciduous  and  supernumerary  teeth.  316 

inferior  first  molar.  319 

inferior  cuspids,  318 

inferior  incisors,  318 

inferior  second  molar,  319 

superior  cuspids,  317 


Deciduous — Cont'd. 

superior  first  molar,  318 
superior  incisors,  317 
superior  second  molar,  318 
teeth.  316 

anatomy  of,  316 
anesthetic  for,  317 
attitude  of  operator  for,  317 
position  of  operator  for,  316 
position  of  patient  for,  316 
that  indicate  extraction,  72 
wedged  roots  of,  319 
tooth,  radiograph  for,  91 
Deep-seated   inferior   first   and   second   mo- 
lar roots,  242 
inferior  incisor  roots,  195 
root,  radiograph  for,  90 
superior    first    and    second    molar    roots, 

166 
superior  third  molar  roots,  178 
Dental  engine,  59 
Dento-alveolar  abscess,  361 
Dento-osseous  structures,  63 
buccal,  64 
labial,  63 
lingual,  67 
palatal,  65 
Dentures,    artificial,    tliat    indicate    extrac- 
tion, 72 
Derenberg  tweezers,  45 
Development,  chronological.  2 
Diagnosis  of  hypercementosis.  323 

of    partial    impaction    of    inferior    third 

molar,  287 
radiographic,   of  complete   impaction   of 

inferior  third  molar,  296 
with  radiograph,  89 
Diathesis,  hemorrhagic,  376 

as  counterindication  to  operating,  76 
Dilated  socket,  356 

Discovery  of  anesthetic  property  of  chloro- 
form. 380 
of  anesthetic  property  of  ether,  379 
of  anesthetic   property   of   ethyl  chlorid, 

379 
of  anesthetic    property    of    nitrous    oxid, 

380 
of  chloroform,  380 
of  ether,  379 
of  ethyl  chlorid,  379 
of  nitrous  oxid.  379 
Disease  of  mandible,  radiograph  for,  91 

of  maxilla,  radiograph  for,  91 
Diseases,  surgical,  about  mouth.  79 
Dislocation  of  mandible.  345 
Displaceinent,    buccal,    of    superior    bicus- 
pids. 148 
complete    buccal,    of    inferior    bicuspids, 
212 
of  inferior  third  molar,  270 
complete  labial,  of  inferior  cuspid,  200 
of  inferior  incisors,  192 
of  superior  central  incisor,  114 
of  superior  cuspid,  136 
of  superior  lateral  incisor.  125 
complete  lingual,    of  inferior   bicuspids, 
210 
of  inferior  cuspid,  200 
of  inferior  incisor,  192 
of  inferior  third  molar.  268 
of  superior  central  incisor,  114 
of  superior  cuspid,  136 
of  superior  lateral  incisor,  124 
lingual,  of  superior  bicuspids,  146 
of  inferior  bicuspids,  210 
of  inferior  cuspid,  200 
of  inferior  first  and  second  molars,  229 
of  inferior  incisors,  192 
of  inferior  third  molar,  268 
of  superior  bicuspids,  146 
of  superior  central  incisor,  114 
of  superior  cuspid,  136 
of  superior  first  and  second  molars,  161 
of  superior  lateral  incisor.  124 
of  superior  third  molar.  176 
partial  buccal,    of    inferior    third    molar, 
272 


398 


INDEX 


Displacement — Cont'd. 

partial  labial,  of  superioi-  cuspid,  137 

of  superior  lateral  incisor,  126 
partial   lingual,  of  inferior  third  molar, 
271 
of  superior  cuspid,  137 
of  superior  lateral  incisor,  126 
partial,  of  inferior  bicuspids,  212 
of  inferior  cuspids,  202 
of  inferior  incisors,  192 
of  superior  central  incisor,  114 
Disturbing-  artificial  restorations,  342 

treatment  in  adjacent  tooth,  343 
Dowel   crown,    examining  root   supporting, 
85 
extracting  root  supporting,  328 
Doyen-Jansen  mouth-gag.  49 
Dry  socket  in  post-extraction  pain,  369 

E 

Effect  of  chloroform  on  the  organism,  389 
of  ether  on  the  organism,  388 
of  ethyl  chlorid  on  the  organism,  387 
of  nitrous  oxid  on  the  organism,  382 
Engine,  dental,  59 
Epilepsy  as  counterindication  to  operating, 

76 
Equipment,  office,  56 
Elevator,  author's  lower  root,  33 
author's  modified  Cryer,  41 
author's  modified  Lecluse,  38 
author's  special,  35 
Cryer,  38 
curved-shank, 30 
for  inferior  incisors,  196 
for  inferior  third  molar,  260 
for  superior  bicuspids,  152 
for  superior  central  incisor,  118 
for  superior  first  and  second  molars,  167 
for  superior  lateral  incisor,  128 
for  superior  third  molar,  178 
history  of  the,  4 
holding  author's  lower  root,  35 
holding  Lecluse,  3S 
Knott,  32 

labial  application  of  curved-shank,  31 
Lecluse,  35 

lingual  application  of  curved  shank,  31 
maximum    value    of,    for    inferior    third 

molar,  254 
position  of  operator  when  employing,  99 
straight-shank,  29 
Elevators,  2  8 

Enamel,  examining  tooth  with  ciiecked,  82 
Ether,  388 

composition  of,  388 
discovery  of,  3'79 

discovery  of  anesthetic  property  of,  379 
effect  of,  on  the  organism,  388 
Ethyl  chlorid,  387 

composition  of,  387 
discovery  of,  379 

discovery  of  anesthetic  property  of,  379 
effect  of,  on  the  organism,  387 
Etiology  of  hypercementosis,  323 

of  impacted  inferior  third  molar,  285 
Examination  after  extraction,  349 

attitude  of  operator  when  making,  77 
instruments  for,  54 
of  mouth,  77 
of  teeth,  77 
radiograph  in,  87 

removing  foreign  bodies  preceding,  79 
Examining  adjacent  teeth,  80,  85 
alveolar  process,  86 
approximate  space,  85 
bridge  abutment,  85 
filled  tooth,  84 
gums,  86 
root  of  tooth,  83 

overlaid  with  gum  tissue,  84 
supporting  do-wel  crown,  85 
supporting  shell  crown,  84 
tissues,  80 
tooth,  80 

attacked  by  caries,  82 


Examining — Cont'd. 

tooth  free  of  caries,  81 

with  checked  enamel,  82 
with  fractured  crown,  81 
treated  tooth,  85 
Excessive  bleeders,  376 
Explorer,  55 

Exposed  alveolar  process,  355 
Extensive  caries  of  inferior  cuspid,  202 
of  inferior  third  molar,  272 
of  superior  bicuspids,  149 
of  superior  central  incisor,  115 
of  superior    first   and   second   molars, 

163 
of  superior  lateral  incisor,  126 
fracture  of  alveolar  process,  353 
External  fistula,  septic  pericementitis  with, 

367 
Extracting  bridge  abutment,  330 
root  supporting  dowel  crown,  328 
tooth  below  bridge,  331 

supporting  shell  crown,  329 
Extraction,    artificial    dentures    that    indi- 
cate, 72 
conditions  that  do  not  indicate,  73 
conditions  that  indicate,  70 
counterindications  to,  70 
deciduous  teeth  that  indicate,  72 
examination  after,  349 
fractured  teeth  that  indicate,  71 
impacted  teeth  that  indicate,  71 
indications  for,  70 
infirmities  that  indicate,  72 
malposed  teeth  that  indicate,  71 
movements  for  inferior  bicuspids,  210 
for  inferior  cuspid,  200 
for  inferior  first   and    second   molars, 

226 
for  inferior  incisors,  190 
for  inferior  third  molar,  263,  267 
for  superior  bicuspids,  144 
for  superior  central  incisors,  112 
for  superior  cuspid,  133 
for  superior  first  and  second  molars, 

159 
for  superior  lateral  incisor,  122 
for  superior  third  molar,  174 
neuralgia  that  indicates,  72 
of  adjacent  tootli.  338 
of  unerupted  tooth,  339 
order  of,  for  inferior  bicuspids,  208 
for  inferior  cuspid,  198 
for  inferior   first    and   second    molars, 

225 
for  inferior  incisors,  188 
for  inferior  third  molar,  255 
for  superior  bicuspids,  144 
for  superior  central  incisor,  111 
for  superior  cuspid,  130 
for  superior  first  and  second  molars, 

157 
for  superior  lateral  incisor,  120 
for  superior  third  molar,  172 
pathologic  conditions  tliat  indicate,  70 
roots  supporting  bridge  that  indicate,  72 
roots  supporting  crown   that  indicate,  72 
supernumerary  teeth  that  indicate,  71 
surgical  cases  that  indicate,  72 
technic  of  hypercementosed  teeth,  326 
of  impacted  inferior  third  molar,  283 
of  inferior  teeth.  184 
of  superior  teeth, 108 
of  supernumerary  teeth,  320 
treatment  after,  248 
traumatism  that  indicates,  72 
utilizing  post  for,  329 
without  complications,  349 
Extractions,  pericementitis  in  multiple,  368 
Extraoral  radiograph,  88 

F 

Pilled  tooth,  examining,  84 
First  and  second  bicuspids,  inferior,  204 
superior,  140 
molar  roots,  deep-seated  inferior,  242 
deep-seated  superior,  166 


INDEX 


399 


First  and  second  molar  roots — Cont'd. 

inferior,  covered  by  gum  tissue,  242 
superior,  covered  by  gum  tissue,  166 
wedged  inferior,  247 

molars,   alveolar   application   of  forceps 
to  inferior,  225 
alveolar  application  of  forceps  to  su- 
perior, 158 
application  of  forceps   to   inferior,  225 
application  of  forceps  to   superior,  158 
caries  of  inferior,  229 
caries  of  superior.  162 
displacement  of  inferior,  229 
displacement  of  superior,  161 
elevator  for  superior,  167 
extensive  caries  of  superior,  163 
extraction  movements  for  inferior, 226 
extraction  movements  for  superior, 159 
forceps  for  inferior,  222 
forceps  for  superior,  154 
fracture  of  inferior,  244 
fracture  of  superior,  168 
fused  roots  of  superior,  163 
impacted  inferior,  244 
impacted  superior,  168 
inferior,  220 

maxillary  sinus  and  superior,  170 
order  of  extraction  for  inferior,  225 
order  of  extraction  for  superior,  157 
position  of  operator  for  inferior,  220 
position  of  operator  for  superior,  154 
position  of  patient  for  inferior,  220 
position  of  patient  for  superior,  154 
screv^r-porte  for  inferior,  244 
screw-porte  for  superior,  167 
separated  roots  of  superior,  165 
superior.  153 

three  roots  united  of  superior,  164 
two  roots  separated  of  inferior,  239 
two  roots  united  of  inferior,  232 
two  roots  united  of  superior,  165 
wedged  superior,  168 

molar,  deciduous  inferior,  319 
deciduous  superior,  318 
forceps  for  superior,  11 
Fistula,    septic    pericementitis    with    exter- 
nal, 367 
Foil  carrier,  54 
Foot-stand,  57 

Forceps,  alveolar  application  of,  to  inferior 
bicuspids,  208 
to  inferior  cuspid,  2C0 
to  inferior    first    and    second    molars, 

225 
to  inferior  incisors,  189 
to  inferior  third  molar,  266 
to  superior  bicuspids,  144 
to  superior  cuspid,  130 
to  superior  central  incisor.  111 
to  superior   first    and   second    molars. 

158 
to  superior  lateral  incisor,  122 
to  superior  third  molar,  174 

application  of,  to  inferior  bicuspids,  208 
to  inferior  cuspid,  199 
to  inferior    first    and    second    molars, 

225 
to  inferior  incisors,  188 
to  inferior  third  molar,  266 
to  superior  bicuspids,  144 
to  superior  central  incisor.  111 
to  superior  cuspid,  130 
to  superior    first   and   second   molars, 

158 
to  superior  lateral  incisor,  122 
to  superior  third  luolar,  174 

author's  improved  lo^ver  molar,  2  7 

comparative  list  of,  22 

for  inferior  bicuspids,  206 

for  inferior  cuspid,  196 

for  inferior  first  and  second  molars,  222 

for  inferior  incisors,  187 

for  inferior  molar,  16 

for  inferior  molar  roots,  16 

for  inferior  teeth,  16 

for  inferior  third  moLar,  255 

for  superior  bicuspid.  11,  140 

for  superior  central  incisor.  10,  110 


Forceps — Cont'd. 

for  superior  cuspid,  10,  129 

for  superior  first  and  second  molars,  1  54 

for  superior  first  molar,  11 

for  superior  lateral  incisor,  10,  120 

for  superior  roots,  16 

for  superior  second  molar,  11 

for  superior  teeth,  10 

for  superior  third  molar,  11,  172 

for  ten  anterior  teeth,  16 

history  of  the,  5 

holding  the,  27 

in  temple  of  Apollo,  1 

Physick,  35 

position    of    operator    when    employing, 
on  inferior  teeth.  96 
when  employing,  on  superior  and  in- 
ferior teeth  at  same  sitting,  98 
when   employing,    on    superior   teeth, 
94 

special,  for  ten  superior  anterior  teeth, 
22 

Standar''d,  No.  1,  10 

Standard,  No.  2,  11 

Standard,  No.  3  L,  11 

Standard,  No.  3  R,  11 

Standard,  No.  4,  11 

Standard,  No.  5,  16 

Standard,  No.  6,  16 

Standard,  No.  7,  16 

Standard,  No.  8,  21 

Standard,  No.  9.  21 

Standard  set  of,  22 

supplementary,     for      inferior     anterior 
teeth,  21 

Tomes',  5 
Forcing  tooth  between  tissues,  341 

into  abscess  cavity,  339 

into  maxillary  sinus,  340 
Foreign  bodies  in  socket,  359 

removing,  preceding  examination,  79 

removing,  preceding-operation,  79 
Fountain  cuspidor,  58 
Fracture,  extensive,  of  alveolar  process,  353 

hemorrhage  in,  336 

informing  patient  of  probable,  333 

of  alveolar  process,  337 

of  alveolus,  radiograph  for,  91 

of  inferior  bicuspids,  219 

of  inferior  cuspid,  203 

of  inferior  first  and  second  molars,  244 

of  inferior  incisors,  193 

of  inferior  third  molar,  276 

of  jaw,  346 

of  maxillary  tuberosity,  337 

of  superior  bicuspids,  152 

of  superior  cuspid,  140 

of  superior  central  incisor,  118 

of  superior  first  and  second  molars,  168 

of  superior  lateral  incisor  root,  127 

of  superior  third  molar.  182 

of  tuberosity,  radiograph  for,  91 

operative  technic  in,  335 

resulting  shock  of,  334 

under  general  anesthetic,  334 
Fractured  crown,  examining  tooth  with,  82 

margin  of  alveolar  process,  352 

septum,  352 

teeth  that  indicate  extraction,  71 
Fractures  of  teeth,  332 

causes  of,  332 
Freezing  as  local  anesthetic,  394 
Fulcrum  for  inferior  third  molar,  256 

impaired,  259 

methods  of  reinforcing,  257 

second  molar  as,  for  inferior  third   mo- 
lar, 256 
Fused    roots    of    superior    first    and    second 
molars,  163 

G 

General  anesthesia,  378 

history,  of,  378 

hypnotism  in,  380 

mesmerism  in.  380 
anesthetic,  fracture  under,  334 
anesthetics.  381 


400 


INDEX 


Gingival  caries  of  superior  third  molar,  176 
margin      of     superior     central     incisor, 

caries  above,  115 
partial,  impacted    superior    tliird   molar, 

179 
Gums,  examining,  S6 

Gum  tissue,  bicuspid  roots  covered  by,  215 
examining  root  overlaid  with,  S4 
inferior    first    and    second    molar    roots 

covered  by,  242 
inferior  third   molar    roots   covered    by, 

275 
superior    central    incisor    root    covered 

by,  116 
superior    first    and    second    molar    roots 

covered  by,  166 
superior  lateral  incisor  root  covered  by, 

127 
superior  third   molar   roots   covered  by, 

178 
traumatic  injury  to,  351 


H 


Health,  impaired,  103 

Heart  lesion  as  counterindication  to  oper- 
ating, 75 
Hemophilia,  376 
Hemorrhage,  372 

in  fracture,  336 

instructing  patient  regarding,  375 

intermediary,  373 

primary,  372 

secondary,  375 
Hemorrhagic  diathesis,  376 

as  counterindication  to  operating,  76 
Historical,  1 
History  of  general  anesthesia,  378 

of  impacted    inferioi-     third     molar,     ob- 
taining. 286 

of  local  anesthesia,  389 

of  the  elevator,  4 

of  the  forceps,  5 

of  the  key,  4 

of  the  pelican,  3 
Holding  author's  lower  root  elevator,  35 

Lecluse  elevator,  38 

the  forceps,  27 
Home   of   patient,    position    of   operator   at, 

100 
Hospital,  position  of  operator  in.  101 
Hypercementosed  teeth,  extraction  technic 

of,  326 
Hypercementosis,  323 

and  artificial  complications,  323 

diagnosis  of,  323 

etiology  of,  323 
Hypnotism  in  general  anesthesia,  380 


Impacted  by  approximating  tooth,  superior 
third  molar,  182 
complete  alveolar,  superior    third    molar. 

181 
inferior  bicuspids,  218 
inferior  cuspid,  203 
inferior  incisors,  193 
inferior  first  and  second  molars,  244 
inferior  third  molar,  248 

etiology  of,  285 

extraction  technic  of  inferior,  283 

obtaining  history  of,  286 

operative  technic  of,  286 

removing  lingual  plate  of,  311 
partial  alveolar,  superior  third  molar,  179 
partial  gingival,    superior    third    molar, 

179 
superior  bicuspids,  152 
superior  cuspid,  137 
superior  first  and  second  molars,  168 
superior  lateral  incisor.  126 
superior  third  molar,  179 
teeth  that  indicate  extraction,  71 
tooth,  radiograph  for,  89 


Impaction,   complete,   of  inferior   third  mo- 
lar. 296 
of    inferior    third    molar,    anestlietic 

for,  298 
of    inferior    tliird    molar    by    insuffi- 
cient space,  300 
of  inferior  third  molar  bv  malforma- 
tion, 302 
of  inferior  third  molar  bv   malposi- 
tion, 302 
of    inferior    third    molar    bv    osseous 

tissue,  299 
of   inferior   third   molar   bv   soft   tis- 
sue, 299 
of   irferior   third    molar,  radiographic 

diagnosis  of,  296 
of   inferior     third     molar,     anesthetic 
for  partial.  288 
partial,  of  inferior  third  molar,  2S7 

of  inferior  third  molar  bv  malforma- 
tion, 291 
of  inferior   third   molar  bv   malposi- 
tion, 291 
of    inferior    third    molar    by    osseous 

tissue,  290 
of   inferior   third   molar   by   soft   tis- 
sue, 2SS 
of    inferior    third    molar    by    super- 
numerary teeth,  295 
of  inferior  third  molar,  diagnosis  of, 
287 
Impaired  fulcrum,  259 

health,  103 
Import  of  anatomical  landmarks,  69 
Improved,  author's,  lower  molar  forceps,  27 
Incisor,  alveolar  application   of  forceps  to 
superior  lateral,  122 
application    of   forceps   to  superior   cen- 
tral, 111 
to  superior  lateral,  122 
caries   above  gingival   margin   of   supe- 
rior central,  115 
caries  of  superior  central,  115 
chisel  for  superior  central,  119 
complete    labial    displacement    of    supe- 
rior central,  114 
of  superior  lateral.  125 
complete  lingual  displacement  of  supe- 
rior central,  114 
of  superior  lateral,  124 
displacement  of  superior  central,  114 

of  superior  lateral,  124 
elevator  for  superior  central,  118 

for  superior  lateral,  128 
extensive  caries  of  superior  central,  115 

of  superior  lateral,  126 
extraction  movements  for  superior  cen- 
tral, 112 
for  superior  lateral,  122 
forceps  for  superior  central,  10,  110 

for  superior  lateral,  10,  120 
order  of  extraction  for  superior  central, 
111 
for  superior  lateral,  120 
partial  displacement  of  superior  central, 

114 
partial   labial   displacement   of  superior 

lateral,  126 
partial    lingual    displacement    of    supe- 
rior lateral,  126 
position    of    operator   for   superior   cen- 
tral, 108 
for  superior  lateral,  120 
position  of  patient  for  superior  central, 
108 
for  superior  lateral,  120 
root,  fracture  of  superior  lateral.  127 
reinforcing  superior  central.  119 
superior  central.  116 

covered  by  gum  tissue,  116 
superior  lateral.  127 

covered  by  gum  tissue.  127 
wedged,  superior  lateral.  128 
roots,  deep-seated  inferior,  195 

inferior,  194 
rotated  superior  lateral.  126 
rotated  superior  central,  115 


INDEX 


401 


Incisor — Cont'd. 

screw-porte  for  superior  central,  118 

for  superior  lateral,  128 
split  root  of  superior  central,  116 
superior  central,  108 
superior  lateral,  120 
Incisors,  alveolar  application  of  forceps  to 
inferior,  189 
application  of  forceps  to  inferior,  188 
complete    labial    displacement    of    infe- 
rior, 192 
complete   lingual   displacement   of  infe- 
rior, 192 
deciduous  inferior,  318 
deciduous  superior,  317 
displacement  of  inferior,  192 
elevator  for  inferior,  196 
extraction  movements  for  inferior,  190 
forceps  for  inferior,  187 
fracture  of  inferior,  193 
impacted  inferior,  193 
inferior,  184 

order  of  extraction  for  inferior,  188 
partial  displacement  of  inferior,  192 
position  of  operator  for  inferior,  184 
position  of  patient  for  inferior,  184 
screw-porte  for  inferior,  195 
Indications  for  extraction,  70 

for  nitrous  oxid  anesthesia,  387 
Infection,  post-operative,  364 
Inferior  anterior  teeth,  forceps  for  ten,  16 

supplementary  forceps  for,  21 
bicuspids,    alveolar    application    of    for- 
ceps to. 208 

application  of  forceps  to,  208 

caries  of,  212 

complete  buccal  displacement  of,  212 

coinplete  lingual  displacement  of,  210 

displacement  of,  210 

extraction  movements  for,  210 

forceps  for,  206 

fracture  of,  219 

impacted,  218 

order  of  extraction  for,  208 

partial  displacement  of,  212 

position  of  operator  for,  204 

position  of  patient  for,  204 

screw-porte  for,  218 
cuspid,  196 

alveolar  application  of  forceps  to,  200 

application  of  forceps  to,  199 

complete  labial  displacement  of,  200 

complete  lingual  displacement    of,  200 

displacement  of,  200 

extensive  caries  of,  202 

extraction  movements  for.  200 

forceps  for,  196 

impacted,  203 

order  of  extraction  for,  198 

partial  displacement  of,  202 

position  of  operator  for,  196 

position  of  patient  for,  196 
cuspids,  deciduous,  318 
first  and  second  bicuspids,  204 
first  and  second  molar  roots  covered  by 
gum  tissue,  242 

deep-seated,  242 

wedged,  247 
first  and  second  molars,  220 

alveolar  application  of  forceps  to,  225 

application  of  forceps  to,  225 

caries  of,  229 

displacement  of,  229 

extraction  movements  for,  226 

forceps  for,  222 

fracture  of,  244 

impacted.  244 

order  of  extraction  for,  225 

position  of  operator  for,  220 

position  of  patient  for,  220 

screw-porte  for,  244 

two  roots  separated  of,  239 
two  roots  united  of.  232 
first  molar,  deciduous,  319 
incisor  roots,  194 

deep-seated, 195 


Infer  ioi- — Cont'd. 
incisors,  184 

alveolar    application    of    forceps    to, 
189 

application  of  forceps  to,  188 

complete  labial  displacement  of,  192 

complete  lingual  displacement  of,  192 

deciduous,  318 

displacement  of.  192 

elevator  for,  196 

extraction  movements  for,  190 

forceps  for.  187 

fiacture  of.  193 

impacted,  193 

order  of  extraction  for,  188 

partial  displacement  of,  192 

position  of  operator  for,  184 

position  of  patient  for,  184 

screw-porte  for,  195 
molar  roots,  forceps  for,  16 
molars,  forceps  for,  16 
second  molar,  deciduous,  319 

isolated,  carious,  248 
teetli,  forceps  for,  16 

extraction  technic  of,  184 

position  of  operator  when  emplojang 
forceps  on,  96 

position  of  patient   for   operation   on, 
96 
third  molar,  248 

alveolar    application    of    forceps    to, 
266 

anesthetic     for     complete     impaction 
of,  298 

anesthetic    for    partial   impaction    of, 
288 

application  of  forceps  to,  266 

complete  buccal   displacement  of,   270 

complete  impaction  of,  296 

complete  impaction  of,  by  insufficient 
space,  300 

complete  impaction  of,  by  malforma- 
tion, 302 

complete  impaction    of,    by    malposi- 
tion, 302 

complete  impaction  of,  bv  osseous  tis- 
sue, 299 

complete  impaction  of,  bv  soft  tissue, 
299 

complete  lingual  displacement  of,  268 

crown  of,  distally  inclined,  272 

diagnosis  of  partial  impaction  of,  287 

displacement  of,  268 

elevator  for, 260 

etiology  of  impacted,  285 

extensive  caries  of.  272 

extraction  movements  for,  263 

extraction  technic  of  impacted,  283 

forceps  for,  255 

fracture  of,  276 

fulcrum  for,  256 

isolated,  279 

maximum  value  of  elevator  for,  254 

obtaining  history  of  impacted,  286 

operative  teclinic  of  impacted,  286 

order  of  extraction  for,  255 

partial  buccal  displacement  of,  272 

partial  impaction  of,  287 

partial  impaction    of,    by    malforma- 
tion, 291 

partial  impaction   of,  by  malposition, 
291 

partial  impaction   of,  by  osseous   tis- 
sue, 290 

partial  impaction    of,    by   soft   tissue. 
288 

partial  impaction  of.  by  supernumer- 
ary teetli.  295 

partial  lingual  displacement  of,  271 

position  of  operator  for,  250 

position  of  patient  for,  250 

roots  covered  by  g-um  tissue,  275 

radiographic    diagnosis    of    complete 
impaction  of,  296 

removing  lingual   plate   of  impacted, 
311 

screw-porte  for  inferior,  27  6 


402 


INDEX 


Inf  ei-ior  third  molar — Cont'd. 
single  root  of,  275 
second  molar  as  fulcrum  for,  256 
two  roots  separated  of.  274 
two  roots  united  of,  273 
Infirmities  that  indicate  extraction,  72 
Informing-  patient  of  probable  fracture,  333 

to  unerupted  tooth,  339 
Injury,  traumatic,  to  alveolar  process,  352 

to  gum  tissue,  351 
Instructing  patient  regarding  hemorrhage, 

375 
Instrument,  breaking  an,  343 
Instruments.  8 

for  examination,  54 
sterilizing.  59 
Intermediary  liemorrhage,  373 
Intraoral  radiograph, 88 
Irregular  margin  of  alveolar  process,  352 
Isolated,    carious    inferior    second    molars, 
248 
inferior  third  molar.  279 
Insufficient    space,    complete    impaction    of 
inferior  third  molar  by,  300 


Jaw,  fracture  of,  346 


K 


Keith  screw-porte,  44 
Key,  history  of  the,  4 
Knott  elevator,  32 


Labial   application  of  curved-shank   eleva- 
tor, 31 
dento-osseous  structures,  63 
displacement,  complete,  of  inferior  cus- 
pid, 200 
complete,  of  inferior  incisors,  192 
complete,  of  superior  central  incisor, 

114 
complete,  of  superior  cuspid,  136 
complete,  of  superior  lateral    incisor, 

125 
partial,  of  superior  cuspid,  137 
partial,  of    superior    lateral     incisor, 
126 
Lancet,  45 

Landmarks,  anatomical,  63 
import  of  anatomical,  69 
Lateral  incisor,  alveolar  application  of  for- 
ceps to  superior.  122 
application  of  forceps  to  superior,  122 
complete  labial    displacement    of    supe- 
rior, 125 
complete  lingual   displacement   of   supe- 
rior, 124 
displacement  of  superior,  124 
elevator  for  superior,  128 
extensive  caries  of  superior,  126 
extraction  movements  for  superior,  122 
forceps  for  superior.  10,  120 
impacted  superior,  126 
order  of  extraction  for  superior,  120 
partial  labial    displacement   of   superior, 

126 
partial  lingual  displacement  of  superior, 

126 
position  of  operator  for  superior,  120 
position  of  patient  for  superior,  120 
root,  fracture  of  superior,  127 
superior,  127 

superior,  covered  by  gum  tissue,  127 
wedged,  superior,  128 
rotated  superior,  126 
screw-porte  for  superior,  128 
superior,  120 
Lecluse  elevator,  35 
author's  modified,  38 
holding,  38 
Lesion,   heart,   as   counterindication   to   op- 
erating, 75 


Lesions,  oral,   caused  by  syphilis.  370 
caused  by  tuberculosis,  370 
other  than  dental,  3  70 
Light,  artificial,  59 

Lingual    application    of   curved-shank    ele- 
vator, 31 
dento-osseous  structures,  67 
displacement,    complete,    of   inferior   bi- 
cvispids,   210 
complete,  of  inferior  cuspid,  200 
complete,  of  inferior  incisors.  192 
complete,  of  inferior  third  molar,  268 
complete,  of  superior  central  incisor, 

114 
complete,  of  superior  cuspid,  136 
complete,  of  superior  lateral  incisor, 

124 
of  superior  bicuspids,  146 
partial,  of  inferior  third  molar.  271 
partial,  of  superior  cuspid.  137 
partial,  of     superior     lateral     incisor, 
126 
plate,    removing,    of    impacted    inferior 
third  molar,  311 
Lip,  bruising  the.  343 
Local  anesthesia,  378,  389 
history  of,  389 
anesthetic,  cocain  as,  393 
freezing  as,  394 
novocain  as.  393 
anesthetics.  392 
conductive  anesthesia.  391 
mucous  anesthesia.  391 
regional  anesthesia.  390 
Long-shank  screw-porte,  with  liandle,  44 

witliout  handle.  44 
Loosening  adjacent  tooth,  342 
Loose  spicula  of  alveolar  process.  352 
Lower  molar  forceps,  author's  improved,  27 
root  elevator,  author's,  33 
holding  author's,  35 

M 

Malformation,  complete  impaction  of  infe- 
rior third  molar  by,  302 
Malposed  teeth  that  indicate  extraction,  71 
Malposition,    complete    impaction    of    infe- 
rior third  inolar  by,  302 
Mandible,  dislocation  of,  345 

radiograph  for  disease  of,  91 
Margin,   fractured,   of  alveolar  process,  352 
irregular,  of  alveolar  process,  352 
sharp,  of  alveolar  process,  352 
Mason  mouth-gag,  49 
Mastoid  chisel,  53 

Maxilla,  radiograph  for  disease  of,  91 
Maxillary  sinus  and  superior  first  and  sec- 
ond molars,  170 
forcing  tooth  into,  340 
pathologic,  368 
radiograph  for,  91 
tuberosity,  fracture  of,  337 
Maximum    value    of    elevator    for    inferior 

third  molar,  254 
Mesmerism  in  general  anesthesia,  380 
Methods  of  reinforcing  fulcrum,  257 

progress  of  modern,  6 
Mirror,  mouth,  54 
Modern  methods,  progress  of,  6 
Modified  Cryer  elevator,  author's,  41 

Lecluse  elevator,  author's.  38 
Molar,    alveolar   application    of   forceps    to 
inferior  third  molar,  266 
of  forceps  to  superior  third,  174 
anesthetic    for    complete    impaction    of 
inferior  third,  298 
for     partial     impaction     of     inferior 
third,  288 
application  of  forceps  to  inferior  third, 
266 
of  forceps  to  superior  third,  174 
caries  of  superior  third,  176 
complete     alveolar     impacted     superior 

third,  181 
complete    buccal    displacement    of    infe- 
rior third,  270 


INDEX 


403 


Molar — Cont'd. 

complete  impaction  of  inferior  third,  296 
of  inferior  third,  bj'  insufficient  space, 

300 
of  inferior    third,    by    malformation, 

302 
of  inferior  third,  by  malposition,  302 
of  inferior    third,    by   osseous   tissue, 

299 
of   inferior  third,  by  soft   tissue.   299 
complete   lingual  displacement   of  infe- 
rior third,  26S 
crown     of    inferior    third,     distally    in- 
clined, 272 
deciduous  inferior  first,  319 
deciduous  inferior  second,  319 
deciduous  superior  first.  31S 
deciduous  superior  second,  31S 
diagnosis  of   partial  impaction   of  infe- 
rior third,  2S7 
displacement  of  inferior  third,  268 

of  superior  third,  176 
elevator  for  inferior  tliird.  260 

for  superior  third.  ITS 
etiology  of  impacted  inferior  third,  285 
extensive  caries  of  inferior  third,  272 
extraction       movements       for       inferior 
third,  263,  266 
for  superior  third,  174 
extraction   technic  of  impacted  inferior 

third.  283 
forceps,  author's  improved  lower,  27 
forceps  for  inferior,  16 
forceps  for  inferior  third,  255 
forceps  for  superior  first,  11 
forceps  for  superior  second,  11 
forceps  for  superior  third,  11,  172 
fracture  of  inferior  third,  276 
fracture  of  superior  third,  1S2 
fulcrum  for  inferior  third,  256 
gingival  caries  of  superior  third,  176 
impacted  inferior  third,  248 
impacted  superior  third,  179 
inferior  third, 248 

isolated,  carious  inferior  second,  248 
isolated  inferior  third,  279 
maximum  value  of  elevator  for  inferior 

third,  254 
obtaining    historv    of   impacted    inferior 

third,  286 
operative    technic    of    impacted    inferior 

third,  286 
order    of    extraction    for    inferior    third, 
255 
for  superior  third,  172 
partial  alveolar  impacted  superior  third, 

272 
partial   buccal   displacement   of  inferior 

third.  272 
partial  gingival  impacted  superior  third, 

179 
partial   impaction  of  inferior  third,  287 
of    inferior    third,    by    malformation, 

291 
of  inferior  third,  by  malposition,  291 
of  inferior  third,    by    osseous    tissue, 

290 
of  inferior   third,   by  soft  tissue,  288 
of  inferior   third,    by    supernumerary 
teeth, 295 
partial  lingual  displacement  of  inferior 

third,  271 
position   of   operator  for  inferior   third, 
250 
for  superior  third,  172 
position  of  patient   for  inferior  third,  250 

for  superior  third,  172 
radiographic  diagnosis  of  complete  im- 
paction of  inferior  third,  296 
removing  lingual  plate  of  impacted  in- 
ferior third.  311 
roots,  deep-seated  inferior  first  and  sec- 
ond, 242 
deep-seated    superior    first    and    sec- 
ond superior,  166 
deep-seated  inferior  third,  178 


Molar — Cont'd. 

roots,  forceps  for  inferior,  16 

inferior  first  and  second,  covered  by 

gum  tissue,  242 
inferior    third,   covered   by   gum   tis- 
sue, 275 
superior  first  and  second,  covered  by 

gum  tissue,  166 
superior  third,   covered  by  gum   tis- 
sue, 178 
wedged  inferior  first  and  second,  247 
screw-porte  for  inferior  third,  276 
second,    as    fulcrum    for    inferior    third 

molar,  256 
separated  roots  of  superior  third,  177 
single  root  of  inferior  third,  275 
superior  third,  170 

impacted    by    approximating    tooth, 
182 
three  roots  united  of  superior  third,  177 
tuberosity  and  superior  third,  174 
two  roots  separated  of  inferior  third,  274 
two  roots   united   of   inferior  third,    273 
two  roots  united  of  superior  third,  177 
Molars,   alveolar  application   of    forceps   to 
inferior  first  and  second,  225 
of  forceps  to   superior   first  and  sec- 
ond, 158 
application    of    forceps    to    inferior   first 
and  second,  225 
of  forceps   to  superior   first  and  sec- 
ond, 158 
caries  of  inferior  first  and  second,  229 

of  superior  first  and  second,  162 
displacement    of   inferior    first   and   sec- 
ond, 229 
of  superior  first  and  second,  161 
elevator   for   superior   first   and    second, 

167 
extensive    caries    of    superior    first    and 

second, 163 
extraction    movements   for  inferior   first 
and  second.  226 
for  superior  first  and  second,  159 
forceps  for  inferior  first  and  second,  222 

for  superior  first  and  second.  154 
fracture  of  inferior  first  and  second,  244 

of  superior  first  and  second,  168 
fused  roots  of  superior  first  and  second, 

163 
impacted  inferior  first  and  second,  244 
impacted  superior  first  and  second,  168 
inferior  first  and  second,  220 
maxillary   sinus   and  superior    first   and 

second,  170 
order  of  extraction  for  inferior  first  and 

second,  225 
position  of  operator  for  first  and  second 
inferior,  220 
for  superior  first  and  second,  154 
position  of  patient  for  inferior  first  and 
second.  220 
for  superior  first  and  second,  154 
screw-porte    for    inferior   first   and   sec- 
ond, 244 
for  superior  first  and  second,  167 
separated    roots    of    superior    first    and 

second,  165 
superior  first  and  second.  153 
supernumerary  teeth  near  superior.  321 
tliree  roots  united   of  superior  first  and 

second. 164 
two  roots  separated  of  inferior  first  and 

second,  239 
two  roots    united    of    inferior    first    and 
second,  232 
of  superior  first  and  second,  165 
wedged  superior  first  and  second,  168 
Morrison  reamer,  42 
Mouth,  examination  of,  77,  78 
mirror,  54 

surgical  diseases  about,  79 
wash.  350 

Thiersch  solution  as,  350 
Mouth-gag.  Allen,  49 
Doyen- Jansen,  49 
Mason,  49 


404 


INDEX 


Movements,     extraction,     for    inferior     first 
and  second  molars,  226 

for  inferior  bicuspids,  210 

for  inferior  cuspid,  200 

for  inferior  incisors,  190 

for  inferior  third  molar,  263,  266 

for  superior  bicuspids,  144 

for  superior  central  incisor,  112 

for  superior  cuspid,  133 

for  superior  first  and  second  molars,  159 

for  superior  lateral  incisor,  122 

for  superior  third  molar.  174 
Mucous  anesthesia,  local,  391  . 

Multiple   extractions,   pericementitis  in,  ub« 

N 

Necrosis  of  extracted  tooth,  368 
Neuralgia  that  indicates  extraction,  72 
Nitrous  oxid,  381 

and  oxygen  apparatus,  384 
apparatus,  59 
composition  of,  381 

anesthesia,    contraindications  for.  38  < 
indications  for,  387 
patient  for,  383 
preliminaries  for,  383 
signs  of,  387 

signs  of  recovery  from,  387 
discovery  of,  379 

discovery  of  anesthetic  property   ot,  380 
effect  of,"  on  the  organism,  382 
technic  of  administration  of.  386 
Novocain  as  local  anesthetic,  393 

O 

Obtaining     history     of     impacted     inferior 

third  molar,  286 
Office  equipment,  56 

Operating,    abscessed    teeth    as    counterin- 
dication  to,  75 
chair,  57 

counterindications  to,  74 
epilepsy  as  counterindication  to,  76 
heart  lesion  as  counterindication  to.  75 
hemorrhagic    diathesis    as    counterindi- 
cation to,  76 
on  child,  position  of  operator  when,  99 
pregnancy  as  counterindication  to,  76 
room,  56 

temporary    ankylosis    as    counterindica- 
tion to,  75 
time  of  day  for,  103 
Operation,  advising  patient  before,  103 

on    inferior    teeth,    position    of    patient 

for,  96 
on  superior  teeth,  position  for,  93,  96 
on  superior   teeth,     position     of    patient 

for,  93 
removing  foreign  bodies  preceding,  79 
unsuccessful,  by  another  operator,  105 
Operative  technic  in  fracture,  335 

of  impacted  inferior  third  molar,  286 
Operator,  attitude   of,   for  deciduous  teeth, 
317 
when  making  examination,  77 
position  of,  at  home  of  patient.   100 
for  deciduous  teeth,  316 
for  inferior  bicuspids.  204 
for  inferior  cuspid,  196 
for  inferior   first  and   second  molars, 

220 
for  inferior  incisors,  184 
for  inferior  third  molar,  250 
for  superior  bicuspids,  140 
for  superior  central  incisor,  108 
for  superior  first  and   second  molars, 

154 
for  superior  cuspid,  129 
for  superior  lateral  incisor,  120 
for  superior  third  molar,  172 
patient  and,  93 
when  employing  elevator,  99 
when  employing  forceps   on    inferior 
teeth,  96 


Operator — Cont'd. 

position  of,  when   employing  forceps  on 
superior     and     inferior     teeth     at 
same  sitting,  98 
when  employing  forceps  on  superior 

teeth,  94 
when  operating  on  child,  99 
unsuccessful  operation  by  another,  105 
Oral  lesions  caused  by  syphilis,  370 
caused  by  tuberculosis,  370 
other  than  dental,  370 
Order  of  extraction  for  inferior  bicuspids, 
208 
for  inferior  cuspid,  198 
for  inferior  first  and  second  molars,  225 
for  inferior  incisors,  188 
for  inferior  third  molar,  255 
for  superior  bicuspids,  144 
for  superior  central  incisor.  111 
for  superior  cuspid,  130 
for  superior  first  and  second  molars,  157 
for  superior  lateral  incisor,  120 
for  superior  third  molar,  172 
Organism,  effect  of  chloroform  on   the,  389 
effect  of  ether  on  the,  388 
effect  of  ethyl  chlorid  on  the,  387 
effect  of  nitrous  oxid  on  the,  382 
Osseous   tissue,   complete   impaction   of  in- 
ferior third  molar  by,  299 
Oxygen,  nitrous  oxid  and,  apparatus,  384 


Pain,   dry  socket  in  post-extraction,   369 

post-extraction,  369 
Palatal  dento-osseous  structures,  65 
Pan,  pus,  58 

Partial    alveolar    impacted    superior    third 
molar.  179 
buccal    displacement    of    inferior    third 

molar,  272 
displacement  of  inferior  bicuspids,  212 
of  inferior  cuspid,  202 
of  inferior  incisors,  192 
of  superior  central  incisor,  114 
gingival  impacted  superior  third  molar, 

179 
impaction  of  inferior  third  molar,  287 
of  inferior    third     molar,     anesthetic 

for.  288 
of  inferior    tliird    molar    by    malfor- 
mation, 291 
of  inferior    third    molar    by    malposi- 
tion. 291 
of  inferior    third    molar    by    osseous 

tissue.  290 
of  inferior    third    molar    by    soft    tis- 
sue, 288 
of  inferior    third    molar   by   supernu- 
merary teeth. 295 
of  inferior  third  molar,  diagnosis  of, 
2  8  V 
labial    displacement   of    superior   cuspid, 
137 
of  superior  lateral  incisor,  126 
lingual    displacement    of    inferior    third 
molar.  271 
of  superior  cuspid.  137 
of  superior  lateral  incisor.  126 
Pathologic  conditions  that  indicate  extrac- 
tion. 70 
maxillary  sinus.  368 
Patient,  advising,  before  operation,  103 
and  operator,  position  of,  93 
care  of,  61 

for  nitrous  oxid  anesthesia,  383 
informing,  of  probable  fracture.  333 
Instructing,   regarding  hemorrhage,  375 
position  of.  for  deciduous  teeth.  316 
for  inferior  bicuspids.  204 
for  inferior  cuspid.  196 
for  inferior  first   and  second   molars, 

220 
for  inferior  incisors.  184 
for  inferior  third  molar.  250 
for  operation  on  inferior  teeth.  96 
for  operation  on  superior  teeth,  93 


INDEX 


405 


Patient — Cont'd. 

position  of,  for  supei'ior  bicuspids,  140 
for  superior  central  incisor,  108 
for  superior  cuspid,  129 
for  superior  first  and  second  molars, 

154 
for  superior  lateral  incisor,  120 
for  superior  tliird  molar,  172 
operator  at  home  of,  100 
Pegr-sliaped  crown  of  supernumerary  tooth, 

320 
Pelican,  history  of  the,  3 
Pericementitis,  acute  septic,  361 
chronic  septic,  365 
in  multiple  extractions,  368 
septic,  with  external  fistula,  367 
Pharynx,  tooth  passing  beyond,  347 
Physick  forceps,  35 

Plate,   removing-  ling-ual,  of  impacted  infe- 
rior third  molar,  311 
Position    for    operation    on    superior    teeth, 
93,  96 
of  operator  at  liome  of  patient,  100 
for  deciduous  teetli,  316 
for  inferior  bicuspids,  204 
for  inferior  cuspid,  196 
for  inferior   first  and    second   molars, 

220 
for  inferior  incisors,  184 
for  inferior  third  molar,  250 
for  superior  bicuspids,  140 
for  superior  central  incisor,  108 
for  superior  cuspid,  129 
for  superior   first  and  second  molars, 

154 
for  superior  lateral  incisor,  120 
for  superior  tliird  molar,  172 
in  liospital,  101 
when  employing  elevator,  99 
when  employing   forceps    on    inferior 

teeth,  96 
when  employing 
and    inferior 
ting,  98 
when  employing 

teeth,  94 
wlien  operating  on  cliild,  99 
patient  and  operator,  93 
patient  for  deciduous  teeth,  316 
for  inferior  bicuspids,  204 
for  inferior  cuspid,  196 
for  inferior  first   and  second   inolars, 

220 
for  inferior  incisors,  184 
for  inferior  third  molar,  250 
for  operation  on  inferior  teeth,  96 
for  operation  on  superior  teeth,  93 
for  superior  bicuspids,  140 
for  superior  central  incisor,  108 
for  superior  cuspid,  129 
for  superior  first  and  second  molars, 

154 
for  superior  lateral  Incisor,  120 
for  superior  tliird  molar,  172 
Positions  for  various  conditions,  98 
Post-extraction  pain,  369 

dry  socket  in, 369 
Post-operative  alveolitis,  361 

Infection,  364 
Post,  utilizing,  for  extraction,  329 
Posterior  teetli,  roots  of,  68 
Precautionary  suggestions,  102 
Preliminaries   for   nitrous   oxid   anesthesia, 

383 
Preliminary  procedure,  102 
Pregnancy  as  counterindication  to  operat- 
ing, 76 
Primary  lieniorrhage,  372 

Probable  fracture,  informing  patient  of,  333 
Probe,  55 

Process,  examining  alveolar,  86 
exposed  alveolar,  355 
extensive  fracture  of  alveolar,  353 
fracture  of  alveolar,  337 
fractured  margin  of  alveolar,  352 
irregular  margin  of  alveolar,  352 
loose  spicula  of  alveolar,  352 
sharp  margin  of  alveolar,  352 


forceps  on  superior 
teetli    at    same    sit- 

forceps   on   superior 


Process — Cont'd. 

traumatic  injury  to  alveolar,  352 
Procedure  outlined  from  radiograph,   92 

preliminary,  102 
Progress  of  modern  methods,  6 
Pus  pan,  58 
Pyorrhea,  tooth  affected  by,  104 

R 

Radiograph,  diagnosis  with,  89 

extraoral,  88 

for  abscessed  tooth,  90 

for  deciduous  tooth,  91 

for  deep-seated  root,  90 

for  disease  of  mandible,  91 

for  fracture  of  alveolus,  91 

for  fracture  of  tuberosity,  91 

for  impacted  tooth,  89 

for  maxillary  sinus,  91 

for  root  below  bridge,  90 

for  suspected  unextracted  root,  90 

for  tooth  below  bridge,  90 

for  unerupted  tooth,  91 

indicated,  when,  89 

in  examination,  87 

indicated,  when,  89 

procedure  outlined  from,  92 
Radiographic    diagnosis    of    complete    im- 
paction   of    Inferior    third    molar 
296 
Reamer,  Morrison,  42 
Reception  room,  61 
Recovery    from     nitrous    oxid    anesthesia, 

signs  of,  387 
Regional  anesthesia,  local,  390 
Reinforcing  fulcrum,  methods  of,  257 

superior  central  incisor  root,  119 
Removing  foreign  bodies  preceding  exam- 
ination, 79 
preceding  operation,  79 

lingual  plate  of  impacted  inferior  third 
molar,  311 
Resistance,     uncertainty     of,     encountered, 

104 
Restorations,  disturbing  artificial,  342 
Rest  room,  61 

Resulting  shock  of  fracture,  334 
Retractor,  53 
Room,  operating,  56 

reception,  61 

rest,  61 
Root  below  bridge,  radiograph  for,  90 

elevator,  author's  lower,  33 
holding  author's  lower,  35 

extracting  supporting  dowel  crown,  328 

fracture  of  superior  lateral  incisor,  127 

of  tooth,  examining,  83 

overlaid  with  gum  tissue,  examining,  84 

radiograph  for  deep-seated,  90 

reinforcing  superior  central   incisor,  119 

single,  of  inferior  third  molar,  275 

split,  of  superior  central  incisor,  116 

superior  central  incisor,  116 

superior  centi-'il  incisor,  covered  by  gum 
tissue,  116 

superior  cuspid,  139 

superior  lateral  incisor,  127 

superior  lateral  incisor,  covered  by  gum 
tissue,  127 

supporting  dowel  crown,  examining,  85 
shell  crown,  examining,  84 

wedged,  superior  lateral  incisor,  128 
Roots,  bicuspid,  149,  215 

bicuspid,  covered  by  gum  tissue,  215 

wedged  between  adjacent  teeth,  216 

deep-seated    inferior    first    and    second 
molar,  242 

deep-seated  inferior  incisor,  195 

deep-seated  superior     first     and     second 
superior  molar,  166 

deep-seated  superior  third  molar,  178 

forceps  for  inferior  molar,  16 

forceps  for  superior,  16 

fused,   of  superior   first  and  second   mo- 
lars,  16.'! 


406 


INDEX 


Roots — Cont'd. 

inferior  first  and  second  molar,  covered 

by  gum  tissue,  242 
inferior  incisor,  194 
inferior  third    molar,    covered    by    gum 

tissue,  275 
of  anterior  teeth,  6S 
of  posterior  teeth,  6S 

separated,    of  superior   first  and   second 
molars,  165 
of  superior  third  molar,  177 
two,     of    inferior    first    and     second 

molars,  239 
two,  of  inferior  third  molar,  274 
superior  first  and  second  molar,  covered 

by  gum  tissue,  166 
superior    third    molar,    covered   by   gum 

tissue,  17S 
supporting  bridge  that  indicate  extrac- 
tion, 72 
supporting  crown  that  indicate  extrac- 
tion, 72 
united,  three,  of  superior  first  and  sec- 
ond molars,  164 
three,  of  superior  third  molar,  176 
two,  of  inferior  first  and  second  mo- 
lars. 232 
two,  of  inferior  third  molar,  273 
two,  of  superior  first  and  second  mo- 
lars. 165 
two.   of  superior  third  molar,  177 
wedged  inferior  first  and  second  molar, 

247 
wedged,  of  deciduous  teeth,  319 
Rotated  superior  central  incisor,  115 
superior  lateral  incisor,  126 


Scissors,  curved,  47 

Screw-porte  for  inferior  bicuspids,  218 
for  inferior  first  and  second  molars,  244 
for  inferior  incisors,  195 
for  inferior  third  molar,  276 
for  superior  bicuspids.  151 
for  superior  central  incisor,  IIS 
for  superior  first  and  second  molars,  167 
for  superior  lateral  incisor,  128 
Keith,  44 
long-shank,  with  handle,  44 

without  handle,  44 
short-shank,  without  handle,  44 
Screw-portes,  41 
Screw,  Serre's,  5 
Secondary  hemorrhage.  375 
Second  bicuspids,  inferior  first  and,  204 
superior  first  and.  140 
molar  as  fulcrum  for  inferior  third  mo- 
lar, 256 
deciduous  inferior.  319 
deciduous  superior.  318 
forceps,  for  superior,  11 
isolated,  carious  inferior,  248 
roots,  deep-seated   inferior   first   and, 

242 
roots,  deep-seated  superior  first  and, 

166 
roots,  inferior    first    and,    covered    by 

gum  tissue,  242 
roots,  superior  first   and,    covered  by 

gum  tissue,  166 
roots,  wedged  inferior  first  and.  247 
molars,    alveolar  application    of   forceps 
to  inferior  first  and.    225 
alveolar    application     of    forceps    to 

superior  first  and,  158 
application  of  forceps  to  inferior  first 

and,  225 
application  of     forceps     to     superior 

first  and,  158 
caries  of  inferior  first  and,  229 
caries  of  superior  first  and.  162 
displacement  of  inferior  first  and,  229 
displacement  of    superior     first    and, 

161 
elevator  for  superior  first  and,  167 


Second  molars — Cont'd. 

extensive  caries  of  superior  first  and, 

163 
extraction  movements      for      inferior 

first  and.    226 
extraction  movements      for     superior 

first  and.  159 
forceps  for  inferior  first  and.  222 
forceps  for  superior  first  and,  154 
fracture  of  inferior  first  and.  244 
fracture  of  superior  first  and,  168 
fused  roots  of  superior  first  and,  163 
impacted  inferior  first  and.  244 
impacted  superior  first  and,  168 
inferior  first  and,  220 
maxillary    sinus    and    superior    first 

and.  170 
order  of   extraction   for   inferior   first 

and,  225 
order  of  extraction  for  superior  first 

and,  157 
position  of  operator  for  inferior  first 

and.  220 
position  of  operator  for  superior  first 

and.  154 
position  of   patient    for    inferior    first 

and,  220 
position  of   patient  for   superior  first 

and,  154 
screw-porte  for    inferior  first  and,  244 
screw-porte  for  superior  first  and,  167 
separated  roots  of  superior  first  and, 

165 
superior  first  and,  153 
three    roots    united   of    superior   first 

and,  164 
two  roots   separated   of   inferior   first 

and.  239 
two  roots  united  of  inferior  first  and, 

232 
two  roots  united  of  superior  first  and, 

165 
wedged  superior  first  and.  168 
Separated   roots   of   superior   first  and   sec- 
ond  molars.    165 
of  superior  third  molar,  177 
Septicemia.  365 

Septic  pericementitis,  acute,  361 
chronic,  365 

with  external  fistula.  367 
Septum,  fractured,  352 
Serre's  screw,  5 

Sharp  margin  of  alveolar  process,  352 
Shell  crown,  examining  root  supporting,  84 

extracting  tooth  supporting,  329 
Shock,  resulting,  of  fracture,  334 
Short-shank    screw-porte.    without   handle, 

44 
Signs  of  nitrous  oxid  anesthesia,  387 

of   recovery  from  nitrous  oxid  anesthe- 
sia. 387 
Single  root  of  inferior  third  molar,  275 
Sinus,  forcing  tooth  into  maxillary,  340 

maxillary,  and  superior  first  and  second 

molars.  170 
pathologic  maxillary.  368 
radiograph  for  maxillary.  91 
Small  supernumerary  teeth.  322 
Socket,  dilated.  356 

dry.  in  post-extraction  pain.  369 
foreign  bodies  in.  359 
Soft  tissue,  complete  impaction  of  inferior 

third  molar  by.  299 
Solution.  Thiersch,  as  mouth  wash.  350 
Space,  examining  approximate,  85 
Special  A  forceps.  Standard.  22 
B  forceps.  Standard.  22 
elevator,  author's.  35 

forceps  for  ten   superior  anterior  teeth, 
22 
Spicula,  loose,  of  alveolar  process,  352 
Split  root  of  superior  central  incisor,  116 
Standard  forceps  No.  1,  10 
forceps  No.  2,  11 
forceps  No.  3  L,  11 
forceps  No.  3  R,  11 
forceps  No.  4,  11 
forceps  No.  5,  16 


INDEX 


407 


standard — Cont'd. 
forceps  No.  6,  16 
forceps  No.  7,  16 

forceps  No.  7,  author's  improved,  27 
forceps  No.  8,  21 
forceps  No.  9,  21 
set  of  forceps,  22 
special  A  forceps,  22 
special  B  forceps,  22 
syringe,  47 
Sterilizing  instruments,  59 

vase,  58 
Sterilizer,  59 

Straight-shank  elevator,  29 
Structures,  buccal  dento-osseous,  64 
dento-osseous,  63 
labial  dento-osseous,  63,  67 
palatal  dento-osseous,  65 
Suggestions,  precautionary,  102 
Superior  anterior  teeth,  special  forceps  for 
ten, 22 
bicuspids,  alveolar  application  of  forceps 
to,  144 

application  of  forceps  to,  144 

buccal  displacement  of,  148 

displacement  of,  146 

elevator  for,  152 

extensive  caries  of,  149 

extraction  movements  for,  144 

fracture  of,  152 

forceps  for,  11,  140 

impacted,  152 

lingual  displacement  of.  146 

order  of  extraction  for,  144 

position  of  operator  for,  140 

position  of  patient  for,  140 

screw-porte  for,  151 

supernumerary  teeth  near,  321 
central  incisor,  108 

alveolar  application   of  forceps  to.  111 

application  of  forceps  to.  111 

caries  above  gingival  margin  of,  115 

caries  of,  115 

chisel  for,  119 

complete  lingual   displacement  of,  114 

displacement  of,  114 

elevator  for,  118 

extensive  caries  of,  115 

extraction  movements  for.  112 

forceps  for,  10, 110 

fracture  of,  118 

order  of  extraction  for.  111 

partial  displacement  of,  114 

position  of  operator  for,  108 

position  of  patient  for,  108 

root,  116 

root  covered  by  gum  tissue,  116 

root,  reinforcing,  119 

rotated,  115 

screwr-porte  for,  118 

split  root  of,  116 
cuspid,  129 

application  of  forceps,  to,  130 

caries  of.  138 

complete  labial  displacement  of,  136 

complete  lingual    displacement  of,  136 

displacement  of,  136 

extraction  movements  for,  133 

forceps  for,  10,  129 

fracture  of,  140 

impacted,  137 

order  of  extraction  for,  130 

partial  labial  displacement  of,  137 

partial  lingual  displacement  of,  137 

position  of  operator  for,  129 

position  of  patient  for,  129 

root,  139 
cuspids,  deciduous,  317 
first  and  second  bicuspids,  140 

molar   roots   covered  by   gum   tissue, 
166 

molar  roots,  deep-seated,  166 

molars,  153 

alveolar  application  of  forceps  to, 

158 
application  of  forceps  to,  158 
caries  of,  162 
displacement  of,  161 


Superior  first  and  second  molars — Cont'd. 
elevator  for,  167 
extensive  caries  of,  163 
extraction  movements  for,  159 
forceps  for,  154 
fracture  of,  168 
fused  roots  of,  163 
impacted,  168 
maxillary  sinus  and,  170 
order  of  extraction  for,  157 
position  of  operator  for,  154 
position  of  patient  for,  154 
screw-porte  for,  167 
separated  roots  of,  165 
three  roots  united  of,  164 
two  roots  united  of,  165 
wedged,  168 
first  molar,  deciduous,  318 

forceps  for,  11 
incisors,  deciduous,  317 
lateral  incisor,  120 

alveolar  application  of  forceps  to,  122 

application  of  forceps  to,  122 

complete  labial  displacement  of,  125 

complete  lingual   displacement  of,  124 

displacement  of,  124 

elevator  for,  128 

extensive  caries  of,  126 

extraction  movements  for,  122 

forceps  for,  10,  120 

impacted,  126 

order  of  extraction  for,  120 

partial  labial  displacement  of,  126 

partial  lingual  displacement  of,  126 

position  of  operator  for,  120 

position  of  patient  for,  120 

rotated,  126 

root,  127 

root  covered  by  gum  tissue,  127 

root,  fracture  of,  127 

root  wedged,  128 

screw-porte  for,  128 
molars,  supernumerary  teeth  near,  321 
roots,  forceps  for,  16 
second  molar,  deciduous,  318 

forceps  for,  11 
teeth,  extraction  technic  of,  108 

forceps  for,  10 

position  of  operator  when  employing 
forceps    on,   94 

position  of  patient   for  operation  on, 
93 

position  for  operation  on,  93,  96 
third  molar,  170 

alveolar  application  of   forceps  to,  174 

application  of  forceps  to,  174 

caries  of,  176 

complete  impacted  superior,  181 

displacement  of,  176 

elevator  for,  178 

extraction  movements  for,  174 

forceps  for,  11,  172 

fracture  of,  182 

gingival  caries  of,  176 

impacted,  179 

impacted  by  approximating  tooth,  182 

order  of  extraction  for,  172 

partial  alveolar  impacted,  179 

partial  gingival  impacted,  179 

position  of  operator  for,  172 

position  of  patient  for,  172 

roots  covered  by  gum  tissue,  178 

roots,  deep-seated,  178 

separated  roots  of,  177 

three  roots  united  of.  177 

tuberosity  and,  174 

two  roots  united  of,  177 
Supernumerary  teeth.  319 

deciduous  and,  316 

extraction  technic  of.  320 

near  superior  bicuspids.  321 

near  superior  molars,  321 

small,  322 

that  indicate  extraction,  71 
tooth,  peg-shaped  crown  of,  320 
Supplementary    forceps    for    Inferior    ante- 
rior teeth.  21 
Suppurative  alveolitis,  acute,  361 


408 


INDEX 


Surgical  cases  that  indicate  extraction,  72 

diseases  about  moutli,  79 
Suspected  unextracted  root,  radiograph  for, 

90 
Syphilis,  oral  lesions  caused  by,  370 
Syringe,  bismuth,  48 

standard,  47 
Syringes,  47 


Technic,     extraction,     of     livpercementosed 
teeth,  326 
of  impacted  inferior  third  molar,  283 
of  inferior  teeth,  184 
of  superior  teeth,  108 
of  supernumerary  teeth,  320 

of  administration  of  nitrous  oxid,  386 

operative,  in  fracture,  335 

of  impacted  inferior  third  molar,  286 
Teeth,    abscessed,    as    counterindication    to 
operating,  75 

deciduous,  316 

deciduous  and  supernumerary,  31G 

deciduous,  that  indicate  extraction,  72 

displaced  by  accident,  347 

examination  of,  77 

examining  adjacent,  SO,  85 

extraction  technic  of  inferior,  184 

extraction  technic  of  superior,  108 

forceps  for  inferior,  16 

forceps  for  superior,  10 

forceps  for  ten  inferior  anterior,  16 

fractured,  that  indicate  extraction,  71 

impacted,  that  indicate  extraction,  71 

loosened  by  accident,  347 

malposed,  that  indicate  extraction,  71 

roots  of  anterior,  68 

roots  of  posterior,  68 

special    forceps    for    ten    superior   ante- 
rior, 22 

supernumerary,  319 

supernumerary  that  indicate  extraction, 
71 

supplementary  forceps    for    inferior   an- 
terior. 21 
Temporary  ankylosis,  106 

as  counterindication  to  operating,  75 
Thiersch  solution  as  mouth  wash,  350 
Tliird    molar,    alveolar    application    of    for- 
ceps to  inferior,  266 

alveolar  application  of  forceps  to  supe- 
rior, 174 

anesthetic    for    complete    impaction    of 
inferior,  298 

anesthetic   for  partial   impaction   of  in- 
ferior, 288 

application  of  forceps  to  inferior,  266 

application  of  forceps  to  superior,  174 

caries  of  superior,  176 

complete  alveolar  impacted  superior,  181 

complete  buccal    displacement    of    infe- 
rior, 270 

complete  impaction  of  inferior,  296 
by  insufficient  space,  300 
by  malformation,  302 
by  malposition,  302 
bv  osseous  tissue,  299 
by  soft  tissue,  299 

complete   lingual   displacement   of  infe- 
rior, 268 

crown  of  inferior,  distally  inclined,  272 

diagnosis  of  partial   impaction   of  infe- 
rior. 287 

displacement  of  inferior,  268 

displacement  of  superior,  176 

elevator  for  inferior,  260 

elevator  for  superior,  178 

etiology  of  impacted  inferior,  285 

extensive  caries  of  inferior,  272 

extraction  movements   for   inferior,  263, 
266 

extraction  movements  for  superior,  174 

extraction  technic  of  impacted  inferior, 
283 

forceps  for  inferior,  255 


Third  molar — Cont'd. 

forceps  for  superior,  11,  172 
fracture  of  inferior,  2  76 
fracture  of  superior,  182 
fulcrum  for  inferior.  256 
gingival  caries  of  superior,  176 
impacted  superior,  179 
inferior,  248 
isolated  inferior,  279 

maximum    value    of    elevator    for    infe- 
rior, 254 
obtaining   history  of  impacted   inferior, 

286 
operative   technic   of  impacted   inferior, 

286 
order  of  extraction  for  inferior,  255 
order  of  extraction  for  superior,  172 
partial  alveolar  impacted  superior,  179 
partial  buccal  displacement  of  inferior, 

272 
partial  gingival  impacted  superior,  179 
partial  impaction  of  inferior,  287 
partial  impaction   of    inferior,    by    mal- 
formation, 291 
by  malposition,  291 
by  osseous  tissue,  290 
by  soft  tissue,  288 
by  supernumerary  teeth,  295 
partial  lingual  displacement  of  inferior, 

271 
position  of  operator  for  inferior,  250 
position  of  operator  for  superior,  172 
position  of  patient  for  inferior,  250 
position  of  patient  for  superior,  172 
radiographic  diagnosis  of  complete  im- 
paction of  inferior,  296 
removing  lingual  plate  of  impacted  in- 
ferior, 311 
roots,  deep-seated  superior,  178 

inferior,  covered  by  gum  tissue,  275 
superior,  covered  by  gum  tissue,  178 
screw-porte  for  inferior,  276 
second    molar   as    fulcrum    for    inferioi', 

256 
separated  roots  of  superior,  177 
single  root  of  inferior,  275 
superior,  170 

impacted  by  approximating  tooth,  182 
three  roots  united  of  superior,  177 
tuberosity  and  superior,  174 
two  roots  separated  of  inferior,  274 
two  roots  united  of  inferior,  273 
two  roots  united  of  superior,  177 
Tliree    roots    united    of    superior    first    and 
second  molars,  164 
of  superior  third  molar,  176 
Time  of  day  for  operating,  103 
Tissue,  examining  root  overlaid  with  gum, 

84 
Tissues,  examining.  80 

forcing  tooth  between,  341 
Toilet  accessories,  60 
Toines'  forceps,  5 
Tongue,  wounding  the,  344 
Tooth  affected  by  pyorrhea,  104 

attacked  by  caries,  examining,  82 
below  bridge,  radiograph  for,  90 
examining,  80 
examining  filled,  84 
examining  root  of,  83 
examining  treated,  85 
free  of  caries,  examining,  81 
passing  beyond  pharynx,  347 
radiograph  for  abscessed,  90 
radiograph  for  deciduous.  91 
radiograph  for  impacted,  89 
radiograpli  for  unerupted.  91 
superior    third    molar    impacted    by    ap- 
proximating, 182 
with  cliecked  enamel,  examining,  82 
with  fractured  crown,  examining,  81 
Toxemia,  365 
Traumatic  injury  to  alveolar  process,  352 

to  gum  tissue,  351 
Traumatism  that  indicates  extraction,  72 
Treated  tooth,  examining,  85 


INDEX 


409 


Treatment  after  extraction,  348 

disturbing-,  in  adjacent  tooth,  343 
Tuberculosis,  oral  lesions  caused  by,  370 
Tuberosity,  fracture  of  maxillary,  337 
radiograph  for  fracture  of,  91 
and  superior  third  molar,  174 
Tweezers,  Derenberg,  45 

Two    roots    separated    of   inferior    first   and 
second  molars,  239 
of  inferior  third  molar,  274 
united  of  inferior  first  and   second  mo- 
lars, 232 
of  inferior  third  molar,  273 
of  superior    first   and    second    molars, 

165 
of  superior  third  molar,  177 

U 

Uncertainty  of  resistance   encountered,   104 
Unerupted  tooth,   extraction  of,   339 

injury  to,  339 

radiogrraph  of,  91 


Unextracted  root,  radiograph  for  sus- 
pected, 90 

Unsuccessful  operation  by  another  oper- 
ator, 105 

Utilizing- post  for  extraction,  329 


"Vase,  sterilizing,  5J 


W 


Wash,  mouth,  350 

Thiersch  solution  as  mouth,  3  50 

Wedge,  wooden,  51 

Wedged    inferior    first    and    second    molar 
roots,  247 
roots  of  deciduous  teeth,  319 
superior  first  and  second  molars,  168 

Wooden  wedge,  51 

Wounding  the  tongue,  344 


GREAT    DENTAL    CAREER    ENDS 

Forty  crowded  years  of  dental  life  came  abruptly  to  a  close  at  the  end 
of  March  when  Doctor  George  B.  Winter  died  suddenly  in  Saint  Louis. 
Not  only  to  those  associated  with  him  but  to  dentists  in  many  coun- 
tries, this  news  brought  deep  regret,  for  Doctor  Winter's  widening 
achievements  had  made  friends  for  him  throughout  the  world. 

First  in  the  field  with  his  textbook  of  exodontia,  published  in  1913, 
Doctor  Winter  has  long  been  recognized  as  the  outstanding  authority 
on  this  subject  and  as  a  pioneer  in  discovering  a  method  of  extrac- 
tion for  impacted  third  molars,  one  of  the  great  contributions  to  den- 
tistry. Invited  to  bring  news  of  his  discovery  to  other  nations,  he  had 
traveled  to  England,  France,  and  almost  every  South  American  coun- 
try giving  clinics  and  showing  his  three-reel  motion  film  of  his  pro- 
cedure. A  former  president  of  the  dental  associations  of  his  city  and 
state  as  well  as  of  the  American  Dental  Association,  Doctor  Winter 
was  also  the  recipient  of  achievement  medals  and  of  honorary  mem- 
berships in  many  foreign  dental  societies. 


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